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What changed in CROSS COUNTRY HEALTHCARE INC's 10-K — 2022 vs 2023

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Paragraph-level year-over-year comparison of CROSS COUNTRY HEALTHCARE INC's 2022 and 2023 10-K annual filings, covering the Business, Risk Factors, Legal Proceedings, Cybersecurity, MD&A and Market Risk sections. Every new, removed and edited paragraph is highlighted side-by-side so you can see exactly what management changed in the 2023 report.

+384 added−388 removedSource: 10-K (2024-02-23) vs 10-K (2023-02-23)

Top changes in CROSS COUNTRY HEALTHCARE INC's 2023 10-K

384 paragraphs added · 388 removed · 289 edited across 6 sections

Item 1. Business

Business — how the company describes what it does

111 edited+29 added−30 removed16 unchanged
Biggest changeLGBTQ+, the Green Group), and participating in the One Tree Planted program to plant more than 3,000 trees in the Northwest region of the United States on behalf of one of our customers. • We successfully maintained the Company’s diversity of corporate employees to include 78% women and more than 40% individuals from underrepresented communities. • We focused on the health and well-being of our employees by establishing a Compassion Fund for corporate employees suffering financial hardships, adding a paid volunteer day off for corporate employees to serve our 8 communities, providing a psychologist and group therapy as needed, continuing our 24/7 hotline for healthcare professionals, and providing a SaaS based platform to all of our employees and four family members for free so they can stay connected through a universe of classes (e.g. yoga, language, psychology and many others). • We successfully transitioned management with a new CEO and president and Chairman of the Board.
Biggest changeWe believe the health and well-being of our employees has a direct impact on the quality of the services they deliver, and we continue to support them through providing the Compassion Fund for corporate employees suffering financial hardships, offering a paid volunteer day off for corporate employees to serve our communities, providing a psychologist and group therapy as needed, and providing a SaaS-based platform to all of our employees, and up to four family members, for free so they can stay connected through a universe of classes (e.g., yoga, language, psychology, and many others).
To successfully execute our business strategy, we rely on our experienced and innovative executive and operational teams. Our executive team has extensive experience in the staffing, workforce solutions, technology services, and healthcare industries. We also foster a culture of performance, talented leadership, and collegiality that promotes the achievement of both company and personal goals.
To successfully execute our business strategy, we rely on experienced and innovative executive and operational teams. Our executive team has extensive experience in staffing, workforce solutions, technology services, and healthcare industries. We also foster a culture of performance, talented leadership, and collegiality that promotes the achievement of both Company and personal goals.
From a candidate attraction standpoint, we have an extensive customer base with hospitals and healthcare facilities, and other healthcare providers, throughout the U.S. As a result, we have a diverse portfolio of assignments for our healthcare professionals to choose from. Healthcare professionals apply with us through our differentiated nursing, locum tenens, and allied healthcare recruitment brands.
From a candidate attraction standpoint, we have an extensive customer base with hospitals, healthcare facilities, and other healthcare providers throughout the U.S. As a result, we have a diverse portfolio of assignments for healthcare professionals to choose from. Healthcare professionals apply with us through our differentiated nursing, locum tenens, and allied healthcare recruitment brands.
Our culture is also infused with a growth mindset that encourages employee internal progression and retention through an array of learning and coaching resources. Employees are held to the ethics standards set forth in our Code of Ethics policy, which also applies to vendors and suppliers.
Our culture is infused with a growth mindset that encourages employee internal progression and retention through an array of learning and coaching resources. Employees are held to the ethics standards set forth in our Code of Ethics policy, which also applies to vendors and suppliers.
Our mission regarding talent management and development is to support organizational results and success by employing strategies to attract, engage, develop, and retain employees, and to partner with our leaders to nurture and grow leadership talent.
Talent Development. Our mission regarding talent management and development is to support organizational results and success by employing strategies to attract, engage, develop, and retain employees, and to partner with our leaders to nurture and grow leadership talent.
Our RPO program provides support to replace or complement a customer’s existing internal recruitment functions for permanent hiring needs and is delivered to healthcare organizations throughout the country and serves to provide creative, cost and operationally efficient hiring support and labor optimization, which leads to improvements in quality of care. 5 • Project Management.
Our RPO program provides support to replace or complement a customer’s existing internal recruitment functions for permanent hiring needs and is delivered to healthcare organizations throughout the country and serves to provide creative, cost and operationally efficient hiring support and labor optimization, which leads to improvements in quality of care. • Project Management.
Today, our workforce solutions include: • Managed Service Programs (MSPs). As healthcare providers continue to adopt centralized, outsourced models for managing contingent labor for both clinical and non-clinical needs, we offer an MSP in which we manage all or a portion of the customer’s staffing needs.
Our workforce solutions include: • Managed Service Programs (MSPs). As healthcare providers continue to adopt centralized, outsourced models for managing contingent labor for both clinical and non-clinical needs, we offer an MSP in which we manage all or a portion of the customer’s staffing needs.
We believe our access to such a large and diverse group of healthcare professionals makes us more attractive to healthcare institutions and facilities seeking healthcare staffing and workforce solutions in the current dynamic marketplace. Our applicant tracking system for our travel nurse and allied business provides a world-class candidate experience.
We believe our access to such a large and diverse group of healthcare professionals makes us more attractive to healthcare institutions and facilities seeking healthcare staffing and workforce solutions in the current marketplace. Our applicant tracking system for our travel nurse and allied professionals business provides a world-class candidate experience.
Our recru iters leverage the Company’s extensive databases of clinicians and healthcare professionals, as well as their expertise in their given specialties, to qualify and place candidates. (3) Credentialing and Quality Management. We screen all of our candidates prior to placement through our credentialing departments.
Our recru iters leverage the Company’s extensive databases of clinicians and healthcare professionals, as well as their expertise in their given specialties, to qualify and place healthcare candidates. (3) Credentialing and Quality Management. We screen all of our healthcare employees prior to placement through our credentialing departments.
Through our adoption of a Human Rights and Labor Rights Policy 9 guided by the International Labour Organization Declaration on Fundamental Principles, our goal is to help increase the enjoyment of human rights within the communities in which we operate.
Through our adoption of a Human Rights and Labor Rights Policy guided by the International Labour Organization Declaration on Fundamental Principles, our goal is to help increase the enjoyment of human rights within the communities in which we operate.
Our goal is to provide work conditions that enable employees to thrive in an environment that is healthy and reduces hazards and health and safety issues, as well as raising awareness on health and safety risks related to our business activities. We believe this drives employee retention and performance, thus allowing us to retain a healthy productive team of individuals.
Our goal is to provide work conditions that enable employees to thrive in an environment that is healthy and reduces hazards and health and safety issues, as well as raising awareness on health and safety risks related to our business activities. We believe this drives employee retention and performance, thus allowing us to retain a healthy productive team.
Leveraging our database of clinicians and artificial intelligence, recruiters match the supply of qualified candidates with the demand for open 3 orders from our customers.
Leveraging our database of clinicians and artificial intelligence, recruiters match the supply of qualified candidates with the demand for open orders from customers.
This policy sets forth our intolerance of discrimination and harassment, our employees’ freedom of association, and the importance we place on the safety and health of our employees. Diversity, Equality, and Inclusion. We are committed to maintaining a diverse workplace that respects everyone’s race, gender, sexual orientation, and physical abilities, as well as diversity of thought.
This policy sets forth our intolerance of discrimination and harassment, our employees’ freedom of association, and the importance we place on the safety and health of our employees. 9 Diversity, Equality, and Inclusion. We are committed to maintaining a workplace that respects everyone’s race, gender, sexual orientation, and physical abilities, as well as diversity of thought.
The principal competitive factors in attracting, retaining, and expanding business with healthcare customers nationally include: (i) understanding the customer’s work environment; (ii) offering a comprehensive suite of services to assist the customer in assessing its personnel needs and partnering with customers to design various customizable alternative solutions; (iii) the timely filling of customers' needs; (iv) price; (v) customer service; (vi) quality assurance and screening capabilities; (vii) risk management policies; (viii) insurance coverage; and (ix) general industry reputation.
The principal competitive factors in attracting, retaining, and expanding business with healthcare customers nationally include: (i) understanding the customer’s environment; (ii) offering a comprehensive suite of services to assist in assessing personnel needs; (iii) partnering with customers to design various customizable alternative solutions; (iv) timely filling of customers’ needs; (v) price; (vi) customer service; (vii) quality assurance and screening capabilities; (viii) risk management policies; (ix) insurance coverage; and (x) general industry reputation.
The Company maintains a number of insurance policies including general liability, workers’ compensation, fidelity, employment practices liability, fiduciary, directors and officers, cyber, property, and professional liability policies. These policies provide coverage subject to their terms, conditions, limits of liability, and deductibles, for certain liabilities that may arise from our operations.
The Company maintains a number of insurance policies including general liability, workers’ compensation, fidelity, employment practices liability, fiduciary, directors and officers, cyber, property, and professional liability policies. These policies provide coverage for certain liabilities that may arise from our operations, subject to the policy’s terms, conditions, limits of liability, and deductibles.
One of our goals is also to continue to grow stockholder value by continuing to deepen our relationships with current customers and healthcare professionals, expanding the number and types of new customers we serve, growing the supply and types of specialties of our healthcare professionals, improving our operating leverage through growth and cost containment, and strengthening and broadening our market presence.
One of our goals is to grow stockholder value by continuing to deepen our relationships with current customers and healthcare professionals, expanding the number and types of new customers we serve, growing the supply and types of specialties of our healthcare professionals, improving our operating leverage through growth and cost containment, and strengthening and broadening our market presence.
The diverse list of customers we serve include healthcare facilities, such as acute and non-acute care facilities, medical group practices, government facilities, and managed care organizations. We recruit these professionals nationally and place them on assignments varying in length from several days up to one year.
The diverse list of customers we serve includes healthcare facilities, such as acute and non-acute care facilities, medical group practices, government facilities, and managed care organizations. We recruit these professionals nationally and place them on assignments varying in length from several days up to one year.
Over the past several years, our workforce solutions have evolved into a total talent management approach as our customers focus on maintaining high-quality patient outcomes, while improving their total labor management to address complex financial, compliance, and other challenges in the healthcare industry.
Over the past several years, our workforce solutions have evolved into a total talent management approach as our customers focus on maintaining high-quality patient outcomes, while improving their total labor management to address complex financial, compliance, and other challenges within the healthcare industry.
We rank as one of the largest firms in travel nurse staffing, per diem nurse staffing, allied healthcare staffing, and locum tenens. Some of our traditional competitors in the workforce solutions, healthcare staffing, and search businesses include: AMN Healthcare Services, CHG Healthcare Services, Jackson Healthcare, Aya Healthcare, ProLink Staffing, 7 Ingenovis Health, and Medical Solutions.
We rank as one of the largest firms in travel nurse staffing, per diem nurse staffing, allied healthcare staffing, and locum tenens. Some of our traditional competitors in the workforce solutions, healthcare staffing, and search businesses include: AMN Healthcare Services, CHG Healthcare Services, Jackson Healthcare, Aya Healthcare, Maxim Healthcare Staffing, ProLink Staffing, Ingenovis Health, and Medical Solutions.
We consider assessments provided by our customers and we work with clinicians and experts from our insurance carriers to determine employment eligibility and potential exposure. We provide workers’ compensation insurance coverage, professional liability coverage, and healthcare benefits for our eligible employed temporary professionals.
We consider assessments provided by our customers and we work with clinicians and experts from our insurance carriers to determine employment eligibility and potential exposure. 4 We provide workers’ compensation insurance coverage, professional liability coverage, and healthcare benefits for our eligible employed professionals.
For the years ended December 31, 2022 , 2021, and 2020, no customer accounted for more th an 10% of our revenue. Our Industry We compete in the U.S. temporary healthcare staffing and workforce solutions markets.
For the years ended December 31, 2023, 2022 , and 2021, no customer accounted for more th an 10% of our revenue. Our Industry We compete in the U.S. temporary healthcare staffing and workforce solutions markets.
In today's environment, healthcare systems that experienced major cost pressures throughout the pandemic are seeking alternatives to lower costs, with a trend towards vendor neutral and tech enabled platforms. Our new technology solutions, such as Intellify TM , will help our healthcare systems customers better manage their spend.
In today’s environment, healthcare systems that experienced major cost pressures throughout the COVID-19 pandemic are seeking alternatives to lower costs, with a trend towards vendor neutral and tech-enabled platforms. Our new technology solutions, such as Intellify ® , will help our customers better manage their spend.
Our databases contain an extensive pool of 4 existing and potential customers and all related recruitment and sales activity. Our financial and human resource systems are managed on enterprise resource planning software suites that manage certain aspects of accounts payable, accounts receivable, general ledger, billing, and human capital management.
Our databases contain an extensive pool of existing and potential customers and all related recruitment and sales activity. Our financial and human resource systems are housed on enterprise resource planning software suites that manage certain aspects of accounts payable, accounts receivable, general ledger, billing, and human capital management.
Complex federal and state laws and regulations govern, among other things, the licensure of professionals, the payment of our employees (e.g., wage and hour laws, employment taxes, and income tax withholdings, etc.), state licensing and reporting requirements, and the general operations of our business, which may be amended from time to time.
Complex federal and state laws and regulations govern, among other things, the licensure of professionals, the payment of our employees (e.g., wage and hour laws, employment taxes, and income tax withholdings), state licensing and reporting requirements, privacy, and our general operations, which may be amended from time to time.
For example, as healthcare systems continue to upgrade their electronic medical records or encounter a labor disruption, we can provide comprehensive project management, a deployment of a full staffing plan, and ultimately an organized volume of quality healthcare professionals during the process so that our customers may continue to deliver quality care. • Retained and Contingent Search.
For example, as healthcare systems continue to upgrade their electronic medical records or encounter a labor disruption, we can provide 5 comprehensive project management, deployment of a full staffing plan, and ultimately an organized volume of quality healthcare professionals during the process so that customers may continue to deliver quality care. • Executive and Contingent Search.
Through our breadth and expertise of value-added workforce solutions, we have the ability to meet a national shift towards a more integrated delivery of healthcare which allows us to assist hospitals and health systems turning to lower-cost, more accessible alternatives, such as outpatient or ambulatory care centers.
Through our breadth of and expertise in value-added workforce solutions and tech-enabled services, we have the ability to meet a national shift towards a more integrated delivery of healthcare, which allows us to assist hospitals and health systems turning to lower-cost, more accessible alternatives, such as outpatient or ambulatory care centers.
Our credentialing processes are designed to ensure that our professionals have the requisite skillsets required by our customers, as well as the aptitude to meet the day-to-day requirements and challenges they would typically encounter on assignments where they are placed.
Our credentialing processes are designed to ensure that professionals have the requisite skill sets required by our customers, as well as the aptitude to meet the day-to-day requirements and challenges they would typically encounter on assignments where they are placed.
Our businesses are operated through a relatively centralized business model servicing all assignment needs of our healthcare professional employees, physicians, and customer healthcare facilities, as well as support activities such as coordinating housing, payroll processing, benefits administration, billing and collections, travel reimbursement processing, customer service, and risk management.
Our businesses are operated through a relatively centralized model, servicing all assignment needs of our healthcare professionals, physicians, and customer facilities, as well as support activities, such as coordinating housing, payroll processing, benefits administration, billing and collections, travel reimbursement processing, customer service, and risk management.
Competition As one of the largest providers of workforce solutions and healthcare staffing in the U.S., we operate on a national, regional, and local basis in a highly competitive industry for both healthcare customers and healthcare professionals. In general, we compete against other national companies, as well as numerous smaller, regional, and local companies.
Competition As one of the largest providers of workforce solutions and healthcare staffing in the U.S., Cross Country operates on a national, regional, and local basis in a highly competitive industry for both healthcare customers and healthcare professionals. In general, we compete against other national companies, as well as numerous smaller, regional, and local companies.
In addition, our competitive benefits generally include professional liability insurance, a 401(k) plan, health insurance, reimbursed travel, per diem allowances, and housing. Recruiters are an essential element of our Nurse and Allied Staffing business and are responsible for establishing and maintaining key relationships with candidates for the duration of their assignments.
Competitive benefits for our employees generally include professional liability and workers compensation insurance, a 401(k) plan, health insurance, reimbursed travel, per diem allowances, and housing. Recruiters are an essential element of our Nurse and Allied Staffing business and are responsible for establishing and maintaining key relationships with candidates for the duration of their assignments.
We have a history of investing in diversity, equality, and inclusion as a key component of the organization’s overall corporate social responsibility program, closely aligned with its core values to create a better future for its people, communities, and its stockholders.
We have a history of investing in diversity, equality, and inclusion as a key component of the organization’s overall CSR program, closely aligned with its core values to create a better future for its people, communities, and its stockholders. Corporate Governance .
We believe nurses and allied professionals are confident we will be able to offer them new assignments as they complete their current assignment. Each of our nurse and allied healthcare professionals is employed by us and is typically paid hourly wages and any other benefits they are entitled to receive during the assignment period.
We believe nurses and allied professionals are confident that we will be able to offer them new assignments as they complete their current assignment. Each of our nurse and allied healthcare professionals is employed by us and is typically paid an hourly wage and receive other benefits they are entitled to receive during the assignment period.
Some of these sophisticated applications are proprietary and are hosted in Tier 1 hosting facilities while other systems are Software as a Service (SaaS) based and hosted by our vendor partners. Our systems maintain detailed information about our customer required skillsets and status which assist us in enabling fulfillment and assignment renewals.
Some of these sophisticated applications are proprietary and are hosted in Tier 1 hosting facilities while other systems are Software as a Service (SaaS)-based and hosted by vendor partners. Our systems maintain detailed information about customer-required skill sets and status, which assists us in enabling fulfillment and assignment renewals.
These activities are performed by a predominantly remote work from where people are most productive team, in addition to a few corporate offices. (6) Information Systems. Various information systems are utilized to run our customer relationship management, recruitment, and placement functions based on our different brands.
These activities are performed by a predominantly remote work team, in addition to a few corporate offices. (6) Information Systems. Various information systems are utilized to run customer relationship management, recruitment, and placement functions based on our different brands.
Our locum tenens line of business, Cross Country Locums, has been certified by the NCQA, the leader in healthcare accreditation, since 2001. We are the first publicly traded staffing firm to obtain The Joint Commission Certification, which we still hold with a Letter of Distinction.
Our locum tenens line of business, Cross Country Locums, has been certified by the NCQA, the leader in healthcare accreditation, since 2001. We are the first publicly traded staffing firm to obtain The Joint Commission Certification, which we still hold with a Letter of Distinction. In 2023, we were once again certified by The Joint Commission with no deficiencies.
Our Physician Staffing segment provides licensed practitioners across a broad array of specialties, as well as certified registered nurse anesthetists (CRNAs), nurse practitioners (NPs), and physician assistants (PAs) under our Cross Country Locums ® brand on temporary assignments throughout the United States (U.S.).
Our Physician Staffing segment provides licensed practitioners across a broad array of specialties, as well as certified registered nurse anesthetists (CRNAs), nurse practitioners (NPs), and physician assistants (PAs) on temporary assignments throughout the United States (U.S.).
From a corporate governance standpoint, we believe establishing a framework that supports integrity and high ethical standards is key to the long-term success of our business. This is the foundation of trust with employees, customers and vendors and is of the utmost importance in all that we do.
We believe a framework that supports integrity and high ethical standards is key to the long-term success of our business. This framework is the foundation of trust with employees, customers and vendors and is of the utmost importance in all that we do.
Regardless of how rates evolve, we are committed to continuing to grow our base of clinicians on assignment and growing our market share. Our Business Model The recruitment and retention of a sufficient number of qualified healthcare professionals to work temporary assignments on our behalf is critical to the success of our business.
Regardless of how rates evolve, we are committed to continuing to grow our base of clinicians on assignment and our market share while maintaining the quality we are known for. Our Business Model The recruitment and retention of a sufficient number of qualified healthcare professionals to work temporary assignments on our behalf is critical to the success of our business.
As part of the evolution of our services, we consider the following: (i) solving the immediate and future needs of our customers and expanding our relationships with them; (ii) enhancing our network of healthcare professionals by improving their experience, and deepening our relationship with them; (iii) expanding our service offerings to reduce sensitivity to economic cycles; (iv) expanding our expertise with various healthcare solutions in various geographic areas of the U.S.; (v) continuing to diversify our customer base to enhance our long-term business prospects; and (vi) enhancing and expanding our technology capabilities to deliver efficient and automated services to our customer healthcare facilities.
As part of this total talent management approach, we consider the following: (i) solving the immediate and future needs of our customers; (ii) enhancing our network of healthcare professionals by improving their experience; (iii) expanding service offerings to reduce sensitivity to economic cycles; (iv) expanding our expertise with various healthcare solutions in various geographic areas of the U.S.; (v) continuing to diversify our customer base to enhance long-term business prospects; and (vi) enhancing and expanding technology to deliver efficient and automated services to customer facilities.
Our total corporate rewards package includes market-competitive pay, healthcare benefits, retirement savings plans, paid time off and family leave, various discount programs, and tuition assistance. Health and Wellness. We are committed to the physical and mental health and well-being of our employees.
Our total corporate rewards package includes market-competitive pay, healthcare benefits, retirement savings plans, paid time off and family leave, various discount programs, and tuition assistance. Health and Wellness. We are committed to the physical and mental health and well-being of our employees. Among other things, we are primarily a remote workforce.
We remain a loyal supporter of the American Red Cross, Leukemia and Lymphoma Society, Breast Cancer Research Foundation, Random Acts of Flowers, Palm Beach Country School Board, and Spirit of Giving Holiday Gift Drive, among others.
We remain a loyal supporter of the American Red Cross, Leukemia and Lymphoma Society, Breast Cancer Research Foundation, Random Acts of Flowers, Alzheimer ’ s Association, Palm Beach County School Board, and Spirit of Giving Holiday Gift Drive, among others.
Physician or advanced practice professionals are independent contractors and enter into agreements with Cross Country Locums to provide medical services at a particular healthcare facility or physician practice group based on terms and conditions specified by that customer, for assignments ranging from a few days up to a year.
Physicians or advanced practice professionals are independent contractors (unless prohibited by applicable law) and enter into agreements with Cross Country Locums to provide medical services at a particular healthcare facility or physician practice group based on terms and conditions specified by that customer, for assignments ranging from a few days up to a year. (2) Sales and Marketing .
One of our executives was included on Staffing Industry Analysts’ 2022 Global Power 150 - Women in Staffing List that recognizes the 100 most influential women in the Americas and 50 additional women internationally, and another executive was included in 2021 and 2020.
One of our executives was included on Staffing Industry Analysts’ 2023 Global Power 150 - Women in Staffing List that recognizes the 100 most influential women in the Americas and 50 additional women internationally, and another executive was included in 2022, as well as a third executive included in 2021.
Another executive has been recognized as one the 10 Most Influential HR Executives to Watch in 2022 by CIO Views magazine. Our Chairman of the Board of Directors was also nominated as a top staffing leader to watch in 2023 for World Staffing Awards.
Another executive has been recognized as a 2023 Diversity, Equity, and Inclusion Influencer by Staffing Industry Analysts, and one of the 10 Most Influential HR Executives to Watch in 2022 by CIO Views magazine. Our Chairman of the 2 Board of Directors was also nominated as a top staffing leader to watch in 2023 for World Staffing Awards.
There can be no assurance that any of the above policies will be adequate for our needs, or that we will maintain all such policies in the future. Services Increasingly, we are called upon by our customers to provide creative and innovative talent sourcing strategies across a continuum of care.
Any of the above policies may not be adequate for our needs, or we may not maintain all such policies in the future. Services We are increasingly called upon by our customers to provide creative and innovative talent sourcing strategies across a continuum of care.
As part of our health and safety program, we partner with employees to help them achieve both their physical and mental welfare by providing education on health topics, facilitating complementary health screenings, and offering resources that include a confidential support line. We foster a sound, respectful, fair, and inclusive workplace.
As part of our health and safety program, we partner with employees to help them maintain both their physical and mental welfare by providing education on health topics, facilitating complementary health screenings, and offering resources that include a confidential support line.
This will require our continued focus on: (i) providing our workforce solutions offerings to new customers; (ii) expanding the services we provide to our current customers, including usage of 2 Intellify TM ; (iii) further diversifying our customer base; (iv) improving our capture rate for current MSP customers; (v) accessing more candidates; and (vi) continuing to modernize our technologies and processes to optimize our relationships with our healthcare professionals and customers.
This requires our continued focus on: (i) providing workforce solutions offerings to new customers; (ii) expanding the services we provide to current customers, including usage of Intellify ® ; (iii) further diversifying our customer base; (iv) accessing more candidates; and (v) continuing to modernize technologies and processes to optimize our relationships with healthcare professionals and customers.
The Nurse and Allied Staffing segment provides workforce solutions and traditional staffing, recruiting, and value-added total talent solutions, including temporary and permanent placement of travel and local nurse and allied professionals, temporary placement of healthcare leaders within nursing, allied, physician, human resources, and managed services programs (MSP) services, education healthcare services, in-home care services, and outsourcing services.
The Nurse and Allied Staffing segment provides traditional staffing, recruiting, and value-added total talent solutions, including: (i) temporary and permanent placement of travel and local nurse and allied professionals, and healthcare leaders within nursing, allied, physician, human resources, and finance; (ii) vendor neutral programs and managed service programs (MSP); (iii) education healthcare services; (iv) in-home care services; and (v) outsourcing services.
In 2020, 2021, and 2022, the Company's Co-Founder & Chairman was named to the Staffing Industry Analysts’ Staffing 100 List of the most notable leaders in the industry.
In 2021, and 2022, the Company’s Co-Founder & Chairman was named to the Staffing Industry Analysts’ Staffing 100 List of the most notable leaders in the industry, and the Company’s Chief Executive Officer (CEO) was named to the list in 2023.
Staffing Industry Analysts September 2022 report estimates the 2022 healthcare staffing markets had an aggregate market size of $55.1 billion, of which $33.1 billion was travel nursing, $7.0 billion was per diem nursing, $9.6 billion was allied health, and $5.4 billion was locum tenens and advanced practitioners.
Staffing Industry Analysts ’ September 2023 report estimates the 2023 healthcare staffing markets had an aggregate market size of $55.7 billion, of which $29.9 billion was travel nursing, $7.0 billion was per diem nursing, $11.6 billion was allied health, and $7.2 billion was locum tenens and advanced practitioners.
Our diverse customer base includes both public and private acute care and non-acute care hospitals, outpatient clinics, ambulatory care facilities, single and multi-specialty physician practices, rehabilitation facilities, Program of All-Inclusive Care for the Elderly (PACE) programs, urgent care centers, local and national healthcare systems, managed care providers, public and charter schools, correctional facilities, government facilities, pharmacies, and many other healthcare providers.
Our diverse customer base includes both public and private acute care and non-acute care hospitals, outpatient clinics, ambulatory care facilities, single and multi-specialty physician practices, rehabilitation facilities, PACE programs, urgent care centers, local and national healthcare systems, managed care providers, public and charter schools, correctional facilities, government facilities, pharmacies, and many other healthcare providers including those in underserved communities.
Department of Education, National Center for Education Statistic Report titled “The Condition of Education" (May 31, 2022), in 2020-21, the number of students ages 3-21 who received special education services under the Individuals with Disabilities Education Act (IDEA) was 7.2 million, or 15% of all public school students.
Department of Education, National Center for Education Statistic Report titled “The Condition of Education” (May 24, 2023), during 6 2021 to 2022, the number of students ages three to 21 who received special education services under the Individuals with Disabilities Education Act (IDEA) was 7.3 million, or 15% of all public school students.
In recent years, several technology-enabled companies have entered the market, though at present we believe the current scale is limited. Seasonality The number of healthcare professionals on assignment with us is subject to seasonal fluctuations which may impact our quarterly revenue and earnings.
In recent years, several technology-enabled companies have entered the market, though at present we believe the current scale is limited. Seasonality The number of healthcare professionals on assignment with us is subject to seasonal fluctuations which may impact quarterly revenue and earnings. Hospital patient census and staffing needs of hospital and healthcare facilities may fluctuate, for example, during flu season.
We believe that our national footprint provides a unique value proposition, as we are able to engage with a broader pool of talent and offer customers a more consultative approach relying on our understanding of the local and regional markets they serve. Since 2021, we have disclosed the following two reportable segments: (1) Nursing and Allied Staffing.
We believe that our national footprint provides a unique value proposition, as we are able to engage with a broader pool of talent and offer customers a more consultative approach relying on our understanding of the local and regional markets they serve.
Employees are able to take paid time off to perform volunteer activities, and are able to donate to a charity of their choice directly from their paychecks, either as a one-time donation or ongoing donations.
Employees are able to take paid time off to perform volunteer activities, and are able to donate to certain charities directly from their pay, either as a one-time or ongoing donation.
Our delivery brands include Cross Country Nurses ® , Cross Country Allied ® , Cross Country Medical Staffing Network ® , Cross Country Search ® , Cross Country Workforce Solutions Group ® , and Cross Country Education ® .
Our delivery brands include Cross Country Nurses ® , Cross Country Allied ® , Cross Country Medical Staffing Network ® , Cross Country Search ® , Cross Country Locums ® , Cross Country Workforce Solutions Group ® , Cross Country Education ® , Intellify ® Talent Solutions, and Data Aggregation Services.
In 2021, we launched Career Pathing, allowing employees to create a growth path to help guide their career development within the Company. We partnered with Strayer University and Capella University to provide our employees with access to flexible degree programs at a discounted cost.
We offer Career Pathing, a system that allows employees to create a path to help guide their career development and growth within the Company. We partner with Strayer University, Excelsior University, and Capella University to provide our employees with access to flexible degree programs at a discounted cost.
We also serve as a direct-hire talent acquisition partner to healthcare organizations and academic institutions throughout the nation providing a full suite of prescriptive talent management solutions, including flexible talent delivery models such as retained, outsourced, and contingent staffing.
We also serve as a direct-hire talent acquisition partner to healthcare organizations and academic institutions throughout the nation, providing a full suite of prescriptive talent management solutions, including flexible talent delivery models such as executive search services for healthcare professionals, as well as contingent search and recruitment process outsourcing services.
In 2022, our executive and clinical leadership teams were comprised of 33% self-identified women. Compensation and Benefits. We are committed to rewarding, supporting, and developing the associates who make it possible to deliver on our strategy. To that end, we offer a comprehensive total rewards program aimed at the varying health, home-life, and financial needs of our diverse corporate associates.
We are committed to rewarding, supporting, and developing the associates who make it possible to deliver on our strategy. To that end, we offer a comprehensive total rewards program aimed at the varying health, home-life, and financial needs of our diverse corporate associates.
Future federal and state legislation or interpretations thereof may require us to change our business practices. Compliance with all of these applicable rules and regulations require a significant amount of resources. We endeavor to be in compliance with all such rules and regulations.
Future federal and state legislation or interpretations thereof may require us to change our business practices. Compliance with all of these applicable rules and regulations requires a significant amount of resources. We endeavor to be in compliance with all such rules and regulations. Corporate Social Responsibility (CSR) The Board of Directors (Board) regularly meets with management to discuss CSR-related topics.
In addition to maintaining engaging and intuitive websites to allow potential applicants to obtain information about our Company and assignment opportunities, in 2020, we launched Cross Country Marketplace, our proprietary on-demand staffing platform, as a one-stop, self-service portal to support the candidates throughout their experience with Cross Country and are continuing to build out as a complete self-service portal that candidates can use across the entire engagement life cycle.
In addition to maintaining engaging and intuitive websites to allow potential applicants to obtain information about the Company and assignment opportunities, we further enhanced Cross Country Marketplace, our proprietary mobile on-demand staffing platform, as a one-stop, self-service portal to support the candidates throughout their experience with Cross Country.
We also mark one or more health observances every month, such as heart health, high blood pressure awareness, men’s health, children’s dental health, and more, which provide additional resources for employees to educate themselves and their families. Talent Development.
Monthly well-being newsletters focus on physical, mental, and financial wellness topics of interest. We also mark one or more health observances every month, such as heart health, high blood pressure awareness, men’s health, children’s dental health, and more, which provide additional resources for employees to educate themselves and their families.
Cybersecurity remains a central focus point across our organization, with dedicated resources, iterative training for all employees, as well as a reliance on third parties engaged to assist us in monitoring and managing systems and devices, as well as detecting cyber threats and preventing breaches. (7) Risk Management, Insurance, and Benefits.
We manage our information systems with internal team members located both in the U.S. and in India. Cybersecurity remains a central focus point across our organization, including dedicated resources, iterative training for all employees, and third parties engaged to assist in monitoring and managing systems and devices, detecting cyber threats, and preventing breaches. (7) Risk Management, Insurance, and Benefits.
According to the Bureau of Labor Statistics' Occupational Outlook Handbook (September 8, 2022), employment of physicians and surgeons is projected to grow 3% from 2021 to 2031, slower than the average for all occupations. Despite limited employment growth, about 23,800 openings for physicians and surgeons are projected each year, on average, over the decade .
According to the Bureau of Labor Statistics’ Occupational Outlook Handbook (September 6, 2023), employment of physicians and surgeons is projected to grow 3% from 2022 to 2032, about as fast as the average for all occupations. About 24,200 openings for physicians and surgeons are projected each year, on average, over the decade .
According to the Bureau of Labor Statistics’ Occupational Outlook Handbook (September 8, 2022), employment of registered nurses is projected to grow 6%, or 195,400, from 2021 to 2031, about as fast as the average for all occupations. The RN workforce is expected to grow from 3.1 million in 2021 to 3.3 million in 2031.
According to the Bureau of Labor Statistics’ Occupational Outlook Handbook (September 6, 2023), employment of registered nurses is projected to grow 6%, or 177,400, from 2022 to 2032, faster than the average for all occupations. The registered nurse workforce is expected to grow from 3.2 million in 2022 to 3.3 million in 2032.
The Bureau also projects the need for an additional 203,200 new RNs each year, on average, through 2031, factoring in nurse retirements and workforce exits. Physician Shortage.
The Bureau of Labor Statistics also projects the need for an additional 193,100 new registered nurses each year, on average, through 2032, factoring in nurse retirements and workforce exits. Physician Shortage.
Item 1. Business. Overview of Our Company Cross Country Healthcare, Inc. (Nasdaq: CCRN) is a leading tech-enabled workforce solutions and advisory firm with 36 years of industry experience and insight. We solve complex labor-related challenges for customers while providing high-quality outcomes and exceptional patient care.
Item 1. Business. Overview of Our Company Cross Country Healthcare, Inc. (Nasdaq: CCRN) is a market-leading, tech-enabled workforce solutions and advisory firm with 37 years of industry experience and insight. We help customers tackle complex labor-related challenges and achieve high-quality outcomes, while reducing complexity and improving visibility through data-driven insights.
Though not a material part of our business, we offer customers other value-added services such as Internal Resource Pool Consulting & Development (IRP), Optimal Workforce Solutions (OWS), and a SaaS-based proprietary vendor-neutral platform, Intellify TM . These services seek to augment our customer’s capabilities with managing, supplementing and outsourcing aspects of their internal processes of managing their workforce.
We offer other value-added services such as Internal Resource Pool (IRP) Consulting & Development, Optimal Workforce Solutions (OWS), and Data Aggregation Services (DAS). These services seek to augment our customer’s capabilities with managing, supplementing, and outsourcing aspects of their internal processes of managing their workforce.
Once fully deployed, our self-service candidate portal, known as Gateway TM , will provide real-time matching to open positions. Staffing Industry Analysts recognized us as a leading healthcare staffing firm in the U.S., with 4% market share in 2021.
Our self-service candidate portal, Xperience TM , provides travel and allied professionals with real-time matching to open positions. 7 Staffing Industry Analysts recognized us as a leading healthcare staffing firm in the U.S., with 4% market share in 2022.
Our objective is to provide a clean, safe, and healthy workplace for our employees and to help preserve the environment of the communities we serve by monitoring and mitigating any undesired effect of our business activities on the environment.
Our objective is to provide a clean, safe, and healthy workplace for our employees and to help preserve the environment of the communities we serve by monitoring and mitigating any undesired effect of our business activities on the environment. We’ve embraced an ongoing effort aimed at reducing our use of finite resources, including our paper shredding and recycling programs.
Employment growth in healthcare is expected to be driven by the aging baby-boomer population and a higher prevalence of chronic conditions. Supply of Nurses.
Within healthcare, the individual and family services industry is projected to increase the fastest with an annual growth rate of 2.2%. Employment growth in healthcare is expected to be driven by the aging baby-boomer population and a higher prevalence of chronic conditions. Supply of Nurses.
During 2022, the largest percentage of our revenue was concentrated in Florida, California, New York, and Tennessee. W e provide services to public and private acute care and non-acute care hospitals, outpatient clinics, ambulatory care facilities, single and multi-specialty physician practices, rehabilitation facilities, urgent care centers, public and charter schools, correctional facilities, government facilities, retailers, and many other healthcare providers.
W e provide services to public and private acute care and non-acute care hospitals, outpatient clinics, ambulatory care facilities, single and multi-specialty physician practices, rehabilitation facilities, PACE programs, urgent care centers, public and charter schools, correctional facilities, government facilities, retailers, and many other healthcare providers.
Our physician credentialing entity, Credent, is also certified by the National Committee for Quality Assurance (NCQA). (4) Payment for Services. Our shared service center processes hours worked by field employees in the time and attendance systems, which in turn generate the billable transactions to our customers. Hours worked by independent contractor physicians are reported to our Cross Country Locums office.
Our shared service center processes hours worked by field employees in various time and attendance systems, which in turn generate billable transactions to our customers. Hours worked by independent contractor physicians are reported to our Cross Country Locums office.
This is why in 2022 and the early part of 2023, we refreshed our Board membership with two new diverse candidates who bring new perspectives, experiences and knowledge to our Board.
With this in mind, Board refreshment and identifying the right expertise to support our strategic initiatives are key. This is why in 2022 and the early part of 2023, we refreshed our Board membership with two directors who bring new perspectives, diversity of background and experiences, and knowledge to our Board.
We foster a sound, respectful, fair, and inclusive workplace and condemn all forms of unlawful and inappropriate conduct such as violence, discrimination, intimidation, harassment, and any behavior that creates a hostile or coercive work environment. In 2022, Cross Country Healthcare was recognized with one of the Best Companies for Happiness Award ™ from Comparably.
We aim to foster a sound, respectful, fair, and inclusive workplace and condemn all forms of unlawful and inappropriate conduct, such as violence, discrimination, intimidation, harassment, and any behavior that creates a hostile or coercive work environment.
Leveraging national and in-market staffing teams, we place highly qualified healthcare professionals in virtually every specialty on travel and per diem assignments, local short-term contracts, and permanent positions. We also place teachers, substitute teachers, and other education specialties at educational facilities, and healthcare leaders within nursing, allied, physician, and human resources at healthcare organizations.
Leveraging national and in-market staffing teams, we place highly qualified healthcare professionals in virtually every specialty on travel and per diem assignments, local short-term contracts, and permanent positions.
Among other things, we provide free biometric healthcare screenings, a 24/7 hotline for healthcare workers who are experiencing emotional stress, and incentives to employees who achieve specific fitness goals through our Burnalong wellness challenge.
We also provide free biometric healthcare screenings, a 24/7 hotline for healthcare workers who are experiencing emotional stress, and incentives to employees who achieve specific fitness goals through our “Burnalong” wellness challenge. Our wellness activity calendar features weekly and monthly events and educational sessions to help employees reach and maintain their health and wellness goals.
While we cannot predict the future, we continuously review facts and incidents associated with professional liability and workers’ compensation claims in order to identify trends and reduce our risk of loss in the future where possible.
Our risk management program is designed to ensure prompt notification of incidents, educational training to our employees, loss analysis, and timely reporting procedures to reduce our risk of exposure. We continuously review facts and incidents associated with professional liability and workers’ compensation claims in order to identify trends and reduce our risk of loss in the future where possible.
The benefits to our customers include cost optimization, increased certainty of supply, and visibility into their labor needs and usage, as well as market insight from our industry expertise on a broad range of topics. • Recruitment Process Outsourcing (RPO).
This includes both the placement of our own healthcare professionals and the utilization of other staffing agencies. The benefits to our MSP customers include cost optimization, increased certainty of supply, visibility into labor needs and usage, and market insight from our industry expertise on a broad range of topics.
We have executed multiple initiatives to enhance our position as a leading, consultative, and strategic partner in the healthcare industry. Some of our key focus areas included personalizing the candidate experience, delivering a superior customer experience, infusing technology-enablement to drive efficiencies and increased productivity, and continuing our commitment to clinical excellence.
Some key focus areas include personalizing the candidate experience, delivering a superior customer experience, infusing technology-enablement to drive efficiencies and increased productivity, and continuing our commitment to clinical excellence.

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Item 1A. Risk Factors

Risk Factors — what could go wrong, per management

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Biggest changeThese assessments are performed at least quarterly and are based on the information available to management at the time and involve a significant amount of management judgment. Based on the new information considered in our reviews, we adjust our loss contingency accruals and our disclosures. We may not have sufficient insurance to cover these risks.
Biggest changeBased on the new information considered in our reviews, we adjust our disclosures and our loss contingency accruals, which may increase as a result of increased litigation claims. We may not have sufficient insurance to cover these risks. Actual outcomes or losses may differ materially from those estimated by our current assessments, which would impact our profitability.
In the event that critical information systems fail or are otherwise unavailable, these functions would have to be accomplished manually, which could impact our ability to, among other things, maintain billing and clinical records reliably, to bill for services efficiently and to maintain our accounting and financial reporting accurately.
In the event that critical information systems fail or are otherwise unavailable, these functions would have to be accomplished manually, which could impact our ability to, among other things, maintain billing and clinical records reliably, bill for services efficiently, and maintain our accounting and financial reporting accurately.
Factors such as changes in reimbursement policies for healthcare expenses, consolidation in the healthcare industry, regulation, litigation and general economic conditions could affect the purchasing practices, operations and the financial health of our customers which could have a negative impact on our business.
Factors such as changes in reimbursement policies for healthcare expenses, consolidation in the healthcare industry, regulation, litigation, and general economic conditions could affect the purchasing practices, operations and financial health of our customers, which could have a negative impact on our business.
We do not control and may be unaware of activities of the sellers before the acquisition, including intellectual property and other litigation or disputes, information security vulnerabilities, violations of laws, policies, rules and regulations, commercial disputes, tax liabilities, and other liabilities.
We do not control and may be unaware of activities of the sellers before the acquisition, including intellectual property disputes and other litigation or disputes, information security vulnerabilities, violations of laws, policies, rules, and regulations, commercial disputes, tax liabilities, and other liabilities.
For example, as a result of our level of indebtedness and the uncertainties arising in the credit markets and the U.S. economy: - we may be more vulnerable to general adverse economic and industry conditions; - we may have to pay higher interest rates upon refinancing or on our variable rate indebtedness if interest rates rise, thereby reducing our cash flows; - we may find it more difficult to obtain additional financing to fund future working capital, capital expenditures, acquisitions, and other general corporate requirements that would be in our long-term interests; - we may be required to dedicate a substantial portion of our cash flow from operations to the payment of principal and interest on our debt, reducing the available cash flow to fund other investments; - we may have limited flexibility in planning for, or reacting to, changes in our business or in the industry; - we may have a competitive disadvantage relative to other companies in our industry that are less leveraged; - we may be required to sell debt or equity securities or sell some of our core assets, possibly on unfavorable terms, in order to meet payment obligations; and - we may not be able to successfully raise capital to execute our mergers and acquisitions strategy.
For example, as a result of our level of indebtedness and the uncertainties arising in the credit markets and the U.S. economy: - we may be more vulnerable to general adverse economic and industry conditions; - we may have to pay higher interest rates upon refinancing or on our variable rate indebtedness if interest rates rise, thereby reducing our cash flows; 18 - we may find it more difficult to obtain additional financing to fund future working capital, capital expenditures, acquisitions, and other general corporate requirements that would be in our long-term interests; - we may be required to dedicate a substantial portion of our cash flow from operations to the payment of principal and interest on our debt, reducing the available cash flow to fund other investments; - we may have limited flexibility in planning for, or reacting to, changes in our business or in the industry; - we may have a competitive disadvantage relative to other companies in our industry that are less leveraged; - we may be required to sell debt or equity securities or sell some of our core assets, possibly on unfavorable terms, in order to meet payment obligations; and - we may not be able to successfully raise capital to execute our mergers and acquisitions strategy.
Risks associated with these initiatives include any increased public focus, including by governmental and nongovernmental organizations, new laws and regulations, increased costs associated with sustainability efforts and/or compliance with laws and regulations, as well as increased pressure to expand our CSR and sustainability disclosures in these areas, make commitments, set targets or establish additional goals and take actions to such targets and goals.
Risks associated with these initiatives include any increased public focus, including by governmental and nongovernmental organizations, new laws and regulations, increased costs associated with sustainability efforts and/or compliance with laws and regulations, as well as increased pressure to expand our CSR and sustainability disclosures in these areas, make commitments, set targets or establish additional goals, and take actions to meet such targets and goals.
Any material changes in the political, economic or regulatory environment that affect the purchasing policies, practices and operations of healthcare organizations, or that lead to consolidation in the healthcare industry, could reduce the funds available to purchase our services or otherwise require us to modify our offerings. 15 We provide our services to hospitals and health systems which pay us directly.
Any material changes in the political, economic, or regulatory environment that affect the purchasing policies, practices, and operations of healthcare organizations, or that lead to consolidation in the healthcare industry, could reduce the funds available to purchase our services or otherwise require us to modify our offerings. We provide our services to hospitals and health systems which pay us directly.
We are required to test goodwill and intangible assets with indefinite lives (such as trade names) annually, to determine if impairment has occurred. Long-lived assets and other identifiable intangible assets are also reviewed for impairment whenever events or changes in circumstances indicate that amounts may not be recoverable.
We are required to test goodwill and intangible assets with indefinite lives (such as trade names) annually, to determine if impairment has occurred. Long-lived assets and other identifiable intangible assets are also reviewed for impairment whenever 20 events or changes in circumstances indicate that amounts may not be recoverable.
These constraints could have a material adverse effect on our business. We could fail to generate sufficient cash to fund our liquidity needs and/or fail to satisfy the financial and other restrictive covenants to which we are subject under our existing indebtedness, which could adversely affect long term growth and results of operations.
These constraints could have a material adverse effect on our business. We could fail to generate sufficient cash to fund our liquidity needs and/or fail to satisfy the financial and other covenants to which we are subject under our existing indebtedness, which could adversely affect long term growth and results of operations.
The financial impact to our healthcare customers from COVID or any other pandemic, epidemic, outbreak of an infectious disease or other public health crisis may also impact their ability to pay for our services timely or altogether, including invoices for services provided prior to such an event that were in process.
The financial impact to our healthcare customers from any pandemic, epidemic, outbreak of an infectious disease or other public health crisis may also impact their ability to pay for our services timely or altogether, including invoices for services provided prior to such an event that were in process.
If hospitals fail to pay the intermediaries for our services or those intermediaries become insolvent or fail to pay us for our services, it could impact our bad debt expense and thus our overall profitability. We also provide comprehensive MSP and other workforce solutions directly to certain of our customers.
If hospitals fail to pay the 12 intermediaries for our services or those intermediaries become insolvent or fail to pay us for our services, it could impact our bad debt expense and thus our overall profitability. We also provide comprehensive MSP and other workforce solutions directly to certain of our customers.
General Business Risks We may face difficulties integrating our acquisitions into our operations and our acquisitions may be unsuccessful, involve significant cash expenditures or expose us to unforeseen liabilities. 18 We continually evaluate opportunities to acquire companies that would complement or enhance our business.
General Business Risks We may face difficulties integrating our acquisitions into our operations and our acquisitions may be unsuccessful, involve significant cash expenditures, or expose us to unforeseen liabilities. We continually evaluate opportunities to acquire companies that would complement or enhance our business.
In addition, application and interpretation of laws sometimes change and those changes may spark regulatory inquiries/investigations as a result, for which we may not be insured and which could adversely affect our business and financial condition.
In addition, application and interpretation of laws sometimes change and those changes may spark regulatory inquiries or investigations as a result, for which we may not be insured and which could adversely affect our business and financial condition.
If we are unable to negotiate hourly rates with intermediaries for the services we provide at these customers which are sufficient to cover administrative fees charged by those intermediaries, it could impact our profitability.
If we are unable to negotiate hourly rates with intermediaries for the services we provide to these customers which are sufficient to cover administrative fees charged by those intermediaries, it could impact our profitability.
Moreover, continuing political and social attention to climate change and environmental issues has resulted in both existing and pending international agreements and national, regional, and local legislation, regulatory measures. reporting obligations, and policy changes. There is increasing societal pressure in some of the areas where we operate to limit greenhouse gas emissions as well as other global initiatives.
Moreover, continuing political and social attention to climate change and environmental issues has resulted in both existing and pending disclosure requirements, international agreements and national, regional, and local legislation, regulatory measures, reporting obligations, and policy changes. There is increasing societal pressure in some of the areas where we operate to limit greenhouse gas emissions as well as other global initiatives.
Other than in California where advanced practitioners are required to be classified as W-2 employees by law, if they were re-classified as employees, we would be subject to, among other things, employment and payroll-related tax claims, 17 as well as any applicable penalties and interest.
Other than in California and Illinois, where advanced practitioners are required to be classified as W-2 employees by law, if they were re-classified as employees, we would be subject to, among other things, employment and payroll-related tax claims, as well as any applicable penalties and interest.
However, the business is still vulnerable to fire, storm, flood, power loss, telecommunications failures, physical or software break-ins and similar events which may prevent personnel from gaining access to systems necessary to perform their tasks in an automated fashion.
However, our business is still vulnerable to fire, storm, flood, power loss, telecommunications failures, physical or software break-ins and similar events which may prevent personnel from gaining access to systems necessary to perform their tasks in an automated fashion.
Such limitations on reimbursement could reduce our customers’ cash flows, hampering the pricing we can charge customers and their ability to pay us. Reimbursement changes in government programs, particularly Medicare and Medicaid, can and do indirectly affect the demand and the prices paid for our services.
Such limitations on reimbursement could reduce our customers’ cash flows, hampering the prices we can charge customers, and reducing their ability to pay us. Reimbursement changes in government programs, particularly Medicare and Medicaid, can and do indirectly affect the demand and the prices paid for our services.
We may be subject to liability in such cases even if our Company's contribution to the alleged injury was minimal or related to one of our subcontractors or its employees. Many of these actions involve large claims and significant defense costs.
We may be subject to liability in such cases even if our Company’s contribution to the alleged injury was minimal or related to one of our subcontractors or its employees. Many of these actions, including class actions, involve large claims and significant defense costs.
Costs of providing our services could change more quickly than we are able to renegotiate bill rates in our active contracts and pay rates with our thousands of healthcare professionals. For example, we offer housing subsidies to some of our healthcare professionals or provide actual housing to other healthcare professionals.
Costs of providing our services could change more quickly than we are able to renegotiate bill rates in our active contracts and pay rates with our thousands of healthcare professionals. For example, we offer housing subsidies to some of our healthcare professionals or directly provide housing to other healthcare professionals.
Our success is dependent upon our ability to develop innovative workforce solutions and quickly adapt to changing marketplace conditions and client needs, including making modifications to our technologies and evolving our technology platform, that may differentiate our services and abilities from those of our competitors.
Our success is dependent upon our ability to develop innovative workforce solutions and quickly adapt to changing marketplace conditions and client needs, including making modifications to our technologies and evolving our technology platform, which may differentiate our services and abilities from those of our competitors.
We cannot predict what effect, if any, market sales of shares held by any stockholder or the availability of these shares for future sale will have on the market price of our common stock. 20 Item 1B. Unresolved Staff Comments. None. 21
We cannot predict what effect, if any, market sales of shares held by any stockholder or the availability of these shares for future sale will have on the market price of our common stock. Item 1B. Unresolved Staff Comments. None.
A failure of any of our corporate employees or healthcare professional to observe our policies and guidelines, relevant customer policies and guidelines or applicable federal, state or local laws, rules and regulations could result in negative publicity, payment of fines or other damages.
A failure of any of our corporate employees or healthcare professionals to observe our policies and guidelines, relevant customer policies and guidelines, or applicable federal, state, or local laws, rules, and regulations could result in negative publicity, payment of fines, or other damages.
Uncertainty regarding or changes to federal healthcare law and the willingness of our hospital, healthcare facilities and physician group customers to develop their own temporary staffing pools, replace core staff who have resigned or retired during the pandemic, or to increase the productivity of their permanent staff may, individually or in the aggregate, significantly affect demand for our temporary healthcare staffing services and may hamper our ability to attract, develop and retain customers.
Uncertainty regarding or changes to federal healthcare law and the willingness of our hospital, healthcare facilities and physician group customers to develop their own temporary staffing pools, replace core staff who have resigned or retired, or to increase the productivity of their permanent staff may, individually or in the aggregate, significantly affect demand for our temporary healthcare staffing services and may 11 hamper our ability to attract, develop, and retain customers.
Our inability to effectively manage our international operations or our violation of a regulation could result in increased costs and adversely affect our results of operations. Our financial results could be adversely impacted by the loss of key management or corporate employee turnover.
Our inability to effectively manage our international operations or our violation of any regulation could result in increased costs and adversely affect our results of operations. Our financial results could be adversely impacted by the loss of key management or corporate employee turnover.
The Medicare Access and CHIP Reauthorization Act of 2015 created a new framework for rewarding physicians for providing higher quality care by establishing two tracks of payment: a merit-based incentive payment system, and Advanced Alternative Payment Models.
The Medicare Access and CHIP Reauthorization Act of 2015 created a certain framework for rewarding physicians for providing higher quality care by establishing two tracks of payment: a merit-based incentive payment system and Advanced Alternative Payment Models.
We currently have sufficient liquidity to operate our business in the normal course. If, however, we were to make an acquisition or enter into a similar type of transaction, our liquidity needs may exceed our current capacity.
We currently have sufficient liquidity to operate our business in the normal course. If, however, we were to close an acquisition or enter into a similar type of transaction, our liquidity needs may exceed our current capacity.
In this regard, failure to comply with ethical, social, product, labor, health and safety, accounting, or environmental standards could jeopardize our reputation and potentially lead to various adverse effects on our business. The strength of our reputation may also depend on the success of our corporate social responsibility ("CSR") and sustainability initiatives, which require company-wide coordination and alignment.
In this regard, failure to comply with ethical, social, product, labor, health and safety, accounting, or environmental standards could jeopardize our reputation and potentially lead to various adverse effects on our business. 15 The strength of our reputation may also depend on the success of our corporate social responsibility (“CSR”) and sustainability initiatives, which require company-wide coordination and alignment.
If we do not comply with the laws and regulations that are applicable to our business, we could incur civil and/or criminal penalties as well as litigation or be subject to equitable remedies. We maintain insurance coverage for employment claims, however, it may not cover all claims against us or continue to be available to us at a reasonable cost.
If we do not comply with the laws and regulations that are applicable to our business, we could incur civil and/or criminal penalties or become subject to litigation or equitable remedies. We maintain insurance coverage for employment claims; however, it may not cover all claims against us or continue to be available to us at a reasonable cost.
To protect ourselves from the cost of these types of claims, we maintain professional malpractice liability insurance, employment practices liability insurance, and general liability insurance coverage with terms and in amounts with deductibles that we believe are appropriate for our operations.
To protect ourselves from the cost of these types of claims, we maintain professional malpractice liability insurance, employment practices liability insurance, and general liability insurance coverage with terms and in amounts with deductibles that we believe are appropriate for our operations, although we do not maintain insurance coverage for wage and hour claims.
All of these effects from the pandemic can result in reduced demand for our services or the cancellation of our healthcare professionals working at those facilities or under contract to provide services at those facilities in the future. These effects have also created specific demand in certain specialties and in specific regions of the country.
All of these effects can result in reduced demand for our services or the cancellation of our healthcare professionals working at those facilities or under contract to provide services at those facilities in the future. These effects may also create specific demand in certain specialties and in specific regions of the country.
The design of any system of controls also is based in part upon certain assumptions about the likelihood of future events, and there can be no assurance that any design will succeed in achieving its stated goals under all potential future conditions; over time, a control may become inadequate because of changes in conditions, or the degree of compliance with the policies or procedures may deteriorate.
The design of any system of controls also is based in part upon certain assumptions about the likelihood of future events, and any design may not succeed in achieving its stated goals under all potential future conditions; over time, a control may become inadequate because of changes in conditions, or the degree of compliance with the policies or procedures may deteriorate.
In our industry, the use of social media platforms has increased, allowing access of social media websites and other internet communication to a broad audience.
In our industry, the use of social media platforms has increased due to the ability to access to a broad audience through social media websites and other internet communication.
The impact of any other legislation to repeal or amend or replace the Affordable Care Act is uncertain and could adversely affect our business and financial condition.
The impact of any legislation to repeal, amend, or replace the Affordable Care Act could also adversely affect our business and financial condition.
We are partially self-insured for our workers' compensation coverage, health 16 insurance coverage, and professional liability coverage for our locum tenens providers. If we become subject to substantial uninsured workers' compensation, medical coverage or medical malpractice liabilities, whether directly or indirectly, our financial results may be adversely affected.
We are partially self-insured for our workers’ compensation coverage, health insurance coverage, and professional liability coverage for our healthcare providers. If we become subject to substantial uninsured workers’ compensation, wage and hour claims, medical coverage, or medical malpractice liabilities, whether directly or indirectly, our financial results may be adversely affected.
Our industry is subject to many complex federal, state, local and international laws and regulations related to, among other things, the licensure of professionals, the payment of our field employees (e.g., wage and hour laws, employment taxes, arbitration agreements, and income tax withholdings, etc.) and the operations of our business generally (e.g., federal, state and local tax laws).
Our industry is subject to many complex federal, state, local, and international laws and regulations related to, among other things, the licensure of professionals, medical malpractice claims and related indemnity claims, the payment of our field employees (e.g., wage and hour laws, employment taxes, arbitration agreements, and income tax withholdings), expense reimbursements, wage transparency, and the operations of our business generally (e.g., federal, state, and local tax laws).
We are subject to business and regulatory risks associated with international operations. We have international operations in India where our Cross Country Infotech, Pvt Ltd. (Infotech) subsidiary is located. Infotech provides in-house information systems development and support services as well as some back-office processing services. We have limited experience in supporting our services outside of North America.
We have international operations in India where our Cross Country Infotech, Pvt Ltd. (Infotech) subsidiary is located. Infotech provides in-house information systems development and support services, as well as some back-office processing services. We have limited experience in supporting our services outside of North America.
If any issues arise post-closing, we may not be entitled to sufficient, or any, indemnification or recourse from the sellers, which could have a material adverse impact on our business and results of operations. Losses caused by natural disasters, such as hurricanes and fires, could cause us to suffer material financial losses.
If any issues arise post-closing, we may not be entitled to, or be able to, collect sufficient, or any, indemnification or recourse from the sellers, which could have a material adverse impact on our business and results of operations. 19 Losses caused by natural disasters, such as hurricanes and fires, the physical effects of climate change, or other unexpected events, could cause us to suffer material financial losses.
In recent years, healthcare providers have become subject to an increasing number of legal actions alleging malpractice, vicarious liability, violation of certain consumer protection acts, negligent hiring, negligent credentialing, or related legal theories.
In recent years, healthcare providers and the Company have become subject to an increasing number of legal actions alleging, among other things, malpractice, vicarious liability, violation of certain consumer protection acts, negligent hiring, negligent credentialing, discrimination, or related legal theories.
In instances where we do not win new MSP opportunities or where other vendors win this MSP, a side-by-side MSP opportunity, or vendor management system (VMS) business with our current customers, the number of professionals we have on assignment at those customers could decrease.
Each of these intermediaries charges an administrative fee. In instances where we do not win new MSP opportunities or where other vendors win this MSP, a side-by-side MSP opportunity, or vendor management system (VMS) business with our current customers, the number of professionals we have on assignment at those customers and/or our spend under management could decrease.
To the extent a significant portion of our employee base unionizes, our labor costs could increase significantly. 14 If our labor costs increase, we may not be able to raise rates to offset these increased costs. Because a significant percentage of our revenues consists of fixed, prospective payments, our ability to pass along increased labor costs is constrained.
If our labor costs increase, we may not be able to raise rates to offset these increased costs. Because a significant percentage of our revenues consists of fixed, prospective payments, our ability to pass along increased labor costs is constrained.
In addition, a target of 476,086 performance stock award grants were outstanding as of February 15, 2023. See Note 14 - Stockholders' Equity to our consolidated financial statements. Vested restricted stock and issuance of common stock related to our awards is eligible for resale in the public market without restriction.
In addition, a target of 413,836 performance stock award grants were outstanding as of February 14, 2024. See Note 14 - Stockholders’ Equity to our consolidated financial statements. Vested restricted stock and common stock issued under our awards is eligible for resale in the public market without restriction.
Patient delivery settings continue to evolve, giving rise to alternative modes of healthcare delivery, such as retail medicine, telemedicine and home health.
Patient delivery settings continue to evolve, including potential changes related to artificial intelligence, giving rise to alternative modes of healthcare delivery, such as retail medicine, telemedicine, and home health.
We may be required to enhance wages and benefits to our employees, which could negatively impact our profitability. Labor union activity is another factor that could adversely affect our labor costs or otherwise adversely impact us.
We may be required to enhance wages and benefits to our employees, which could negatively impact our profitability. Labor union activity is another factor that could adversely affect our labor costs or otherwise adversely impact us. To the extent a significant portion of our employee base unionizes, our labor costs could increase significantly.
If our insurance does not cover the particular claim or if we are unable to pay our self-insured retention portion, pay any uninsured portion, or maintain adequate insurance coverage, we may be exposed to substantial liabilities that would materially impact our business and financial performance.
If our insurance does not cover the particular claim or if we are unable to pay our self-insured retention portion, pay any uninsured portion, or maintain adequate insurance coverage, we may be exposed to substantial liabilities that would materially impact our business and financial performance. 16 We are subject to various litigation, claims, investigations, and other proceedings which could result in substantial judgments, settlement costs, or uninsured liabilities.
In addition, if hospitals continue to consolidate in an effort to enhance their market positions, improve operational efficiency, hire permanent replacements to replace core staff, and create organizations capable of managing population health, demand for our services could decrease.
In addition, if hospitals continue to consolidate in an effort to enhance their market positions, improve operational efficiency, hire permanent replacements to replace core staff, and create organizations capable of managing population health, demand for our services could decrease. The staffing industry has experienced a marked decline in revenue in the post-COVID era in light of shifting customer needs.
We have outsourced certain critical applications or business processes to external providers, including but not limited to background screenings of our employees. We exercise care in the selection and oversight of these providers.
We have outsourced certain critical applications or business processes to external providers, including, but not limited to, background screenings of our employees. We exercise care in the selection and oversight of these providers. However, the failure or inability of one or more of these critical suppliers to perform could cause significant disruptions and increased costs to our business.
We believe our judgments in this area are reasonable and correct, but there is no guarantee that we will be successful if challenged by a taxing authority.
We believe our 17 judgments in this area are reasonable and correct, but we may not be successful if challenged by a taxing authority.
Stock issuable under our stock incentive plans are presently in effect and sales of this stock could cause our stock price to decline. We have registered 3,000,000 shares of common stock for issuance under our 2020 Omnibus Incentive Plan. Shares of restricted stock outstanding as of February 15, 2023 were 673,585.
Stock is issuable under our stock incentive plan and sales of this stock could cause our stock price to decline. We have registered 3,000,000 shares of common stock for issuance under our 2020 Omnibus Incentive Plan. Shares of restricted stock outstanding as of February 14, 2024 were 538,098.
Furthermore, increasing attention to climate change has resulted in governmental investigations and public and private litigation, which could increase our costs or otherwise adversely affect our business or results of operations.
Furthermore, increasing attention to climate change has resulted in governmental investigations and public and private litigation, which could increase our costs or otherwise adversely affect our business or results of operations. Any or all of these initiatives may result in significant operational changes and expenditures and could materially adversely affect our business, financial condition, and results of operations.
Our ability to utilize our NOLs is also dependent, in part, upon us having sufficient future earnings to utilize our state NOLs before they expire. If market conditions change materially and we determine that we will be unable to generate sufficient taxable income in the future to utilize our state NOLs, we could be required to record additional valuation allowance.
If market conditions change materially and we determine that we will be unable to generate sufficient taxable income in the future to utilize our state NOLs, we could be required to record additional valuation allowances.
If hospitals change the method for paying locum tenens physicians to meet their performance goals or other criteria for Medicaid or Medicare reimbursements, the profitability of our business could be adversely impacted.
If hospitals change the method for paying locum tenens physicians to meet their performance goals or other criteria for Medicaid or Medicare reimbursements, the profitability of our business could be adversely impacted. Legislative or regulatory initiatives related to CSR and ESG matters could have a material adverse effect on our business.
In addition, we may be subject to claims related to torts or crimes committed by our corporate employees or healthcare professionals that we place on assignment. In most instances, we are required to indemnify customers against some or all of these risks.
In addition, we may be subject to claims related to torts or crimes committed by our corporate employees or healthcare professionals that we place on assignment.
Factors we currently consider immaterial and factors we currently do not know may also materially adversely affect our business or our consolidated results, financial condition, or cash flows.
Factors we currently consider immaterial and factors we currently do not know may also materially adversely affect our business or our consolidated results, financial condition, or cash flows. Business, Economic, and Industry Risks Our operations and financial results may be affected by pandemics, epidemics, or other public health crises.
Intermediaries typically enter into contracts with hospitals or health systems and then subcontract with us and other agencies to provide staffing services, thus interfering to some extent in our relationship with our customers. Each of these intermediaries charges an administrative fee.
We continue to see our customers use intermediary organizations and an increase in the use of side-by-side managed service providers. Intermediaries typically enter into contracts with hospitals or health systems and then subcontract with us and other agencies to provide staffing services, thus interfering to some extent in our relationship with our customers.
We could suffer adverse tax and other financial consequences if taxing authorities do not agree with our tax positions, if there are further legislative tax changes, or if we are unable to utilize our net operating losses. We are periodically subject to a number of tax examinations by taxing authorities in the states and countries where we do business.
We continuously monitor changes in regulations and legislation for potential impacts on our business. We could suffer adverse tax and other financial consequences if taxing authorities do not agree with our tax positions, if there are further legislative tax changes, or if we are unable to utilize our net operating losses (NOLs).
To the extent that these payroll systems experience a disruption or delay in reporting time worked by our healthcare professionals, we may not be able to make payroll to our healthcare workers timely. This could result in significant dissatisfaction by our healthcare workers and damage to our reputation, in addition to violations of certain laws or regulations.
In addition, we rely on third-party timekeeping systems in certain circumstances to process payroll. To the extent that these payroll systems experience a disruption or delay in reporting time worked by our healthcare professionals, we may not be able to make payroll to our healthcare workers timely.
If an event of default exists, our lenders could call the indebtedness and we may be unable to renegotiate or secure other financing.
Deterioration in our operating results could result in our inability to comply with this covenant and would result in a default under our credit facility. If an event of default exists, our lenders could call the indebtedness and we may be unable to renegotiate or secure other financing.
Risks Relating to Our Indebtedness We have a level of indebtedness which may have an adverse effect on our business or limit our ability to take advantage of business, strategic or financing opportunities. As of December 31, 2022, we had a total principal amount of $150.7 million in debt.
Risks Relating to Our Indebtedness We could have a level of indebtedness which may have an adverse effect on our business or limit our ability to take advantage of business, strategic, or financing opportunities. As of December 31, 2023, we had no borrowings under our Asset-Based Loan Agreement (ABL).
These increased costs may not be able to be passed on to customers. In addition, if government regulations were implemented that limited the amount we could charge for our services, our profitability could be adversely affected. We continuously monitor changes in regulations and legislation for potential impacts on our business.
For example, some states could impose sales taxes or increase sales tax rates on temporary healthcare staffing services. These increased costs may not be able to be passed on to customers. In addition, if government regulations were implemented that limited the amount we could charge for our services, our profitability could be adversely affected.
Our ability to generate profitability and maintain cash flow from operations could impact our compliance with these covenants; and (iii) we may choose to institute self-imposed limits on our indebtedness based on certain considerations including market interest rates, our relative leverage and our strategic plans.
A change in our level of indebtedness could have important negative consequences including: (i) increased demands on our cash resources to service the debt; (ii) our financial and operating flexibility may be restricted due to debt covenants to which we are subject, and our ability to generate profitability and maintain cash flow from operations could impact our compliance with these covenants; and (iii) we may choose to institute self-imposed limits on our indebtedness based on certain considerations including market interest rates, our relative leverage, and our strategic plans.
We also have a significant amount of business and employees in California, which is vulnerable to wild-fires and earthquakes. The extent of losses from a catastrophe is a function of both the total amount of insured exposure and the severity of the event. We do not maintain business interruption insurance for these events.
We also have a significant amount of business and employees in California, which is vulnerable to wildfires and earthquakes. Over time, these conditions could result in increases in our operating costs or business interruptions. The extent of losses from a catastrophe is a function of both the total amount of insured exposure and the severity of the event.
In addition, an economic downturn, inflation, recession, and slow recovery, could negatively impact our, or our customer's, results of operations and financial condition. Although we monitor our credit risks to specific customers that we believe may present credit concerns, default risk or lack of access to liquidity may result from events or circumstances that are difficult to detect or foresee.
Although we monitor our credit risks to specific customers that we believe may present credit concerns, default risk or lack of access to liquidity may result from events or circumstances that are difficult to detect or foresee. We are subject to business and regulatory risks associated with international operations.
If we were to lose any required state licenses, we could be required to cease operating in those states. The introduction of new regulatory provisions could also substantially raise the costs associated with hiring temporary employees. For example, some states could impose sales taxes or increase sales tax rates on temporary healthcare staffing services.
Several states have adopted wage transparency or equity laws that have complex reporting requirements. If we were to lose any required state licenses, we could be required to cease operating in those states. The introduction of new regulatory provisions could also substantially raise the costs associated with hiring temporary employees.
Healthcare workers are burned out from the emotional and physical stress of the prolonged pandemic, and the shortage of supply continues as core staff also leave their jobs.
Healthcare workers can become burned out from the emotional and physical stress of a prolonged pandemic, as occurred during the COVID-19 pandemic, which may result in shortage of supply if core staff members leave their jobs.
We could suffer material financial losses as a result of disruptions from hurricanes, fires, or other catastrophes. Legislative or regulatory initiatives related to climate change could result in significant operational changes and expenditures and adversely affect our business, financial condition, and results of operations.
To the extent any of these events occur, our operations and financial results could be adversely affected. Legislative or regulatory initiatives related to climate change could result in significant operational changes and expenditures and adversely affect our business, financial condition, and results of operations.
Such a failure to pay for our services timely or altogether would have an impact on our collections, resulting in a negative financial impact on our Company.
Such a failure to pay for our services timely or altogether would have an impact on our collections, resulting in a negative financial impact on our Company. Global economic conditions and the effect of economic pressures could lead to decreases in demand or pricing for our services, which would adversely affect the profitability of our business.
Any substantial economic downturn, including significant inflationary pressures, could have a material adverse effect on our business, financial condition, or operating results. 11 We may face challenges competing in the marketplace if we are unable to anticipate and quickly respond to changing marketplace conditions, such as alternative modes of healthcare delivery, reimbursement, and customer needs.
We may face challenges competing in the marketplace if we are unable to anticipate and quickly respond to changing marketplace conditions, such as alternative modes of healthcare delivery, reimbursement, and customer needs.
Greenhouse gases may have an adverse effect on global temperatures, weather patterns, and the frequency and severity of extreme weather and natural disasters. Such events could have a negative effect on the Company’s business.
Changes in global temperatures, weather patterns, negative global climate change patterns, and increases in the frequency and severity of extreme weather and natural disasters in both the U.S. and India locations could have a negative effect on the Company’s business.
Our customers may terminate or not renew their contracts with us. Our arrangements with hospitals, healthcare facilities and physician group customers are generally terminable upon 30 to 90 days’ notice. We may have fixed costs, such as housing costs, associated with terminated arrangements that we will be obligated to pay post-termination, thus negatively impacting our profitability.
Our customers may terminate or not renew their contracts with us. Our arrangements with hospitals, healthcare facilities, and physician group customers are generally terminable by the customer upon 30 to 90 days’ notice.
Any or all of these initiatives may result in significant operational changes and expenditures and could materially adversely affect our business, financial condition, and results of operations. 19 Due to inherent limitations, there can be no assurance that our system of disclosure and internal controls and procedures will be successful in preventing all errors and fraud, or in making all material information known in a timely manner to management.
Due to inherent limitations, our system of disclosure and internal controls and procedures may not be successful in preventing all errors and fraud, or in making all material information known in a timely manner to management.
If our healthcare facility customers increase the use of intermediary organizations it could impact our profitability and our ability to secure contracts with customers. 12 We continue to see our customers use intermediary organizations and an increase in the use of side-by-side managed service providers.
In addition, the loss of one or more of our large customers could materially and adversely affect our profitability. If our healthcare facility customers increase the use of intermediary organizations, it could impact our profitability and our ability to secure contracts with customers.
We evaluate these litigation claims and legal proceedings to assess the likelihood of unfavorable outcomes and to estimate, if possible, the amount of potential losses. Based on these assessments and estimates, if any, we establish reserves and/or disclose the relevant litigation claims or legal proceedings, as appropriate.
Based on assessments and estimates, if any, we establish reserves and/or disclose the relevant litigation claims or legal proceedings, as appropriate. These assessments are performed at least quarterly and are based on the information available to management at the time and involve a significant amount of management judgment.
We are subject to various litigation, claims, investigations, and other proceedings which could result in substantial judgment, settlement costs, or uninsured liabilities. We are party to various litigation, claims, investigations, and other proceedings. These matters primarily relate to employee-related matters that include individual and collective claims, professional liability, tax, and payroll practices.
We are party to various litigation, claims, investigations, and other proceedings. These matters primarily relate to employee-related matters that include individual and collective claims, professional liability, tax, and payroll and/or related practices. We evaluate these litigation claims and legal proceedings to assess the likelihood of unfavorable outcomes and to estimate, if possible, the amount of potential losses.
In periods of economic downturn or high inflation, permanent healthcare staff generally work more hours, resulting in fewer vacancies and less demand for our services. Decreases in demand or pricing for our services may also affect our ability to provide attractive assignments to our healthcare professionals.
As admissions decrease, customers typically reduce their use of temporary employees or other healthcare professionals before undertaking layoffs of their permanent employees. In periods of economic downturn or high inflation, permanent healthcare staff generally work more hours, resulting in fewer vacancies and less demand for our services.
Catastrophes can be caused by various events, including, but not limited to, hurricanes, fires, and other severe weather. The incidence and severity of catastrophes are inherently unpredictable.
Catastrophes can be caused by various events, including, but not limited to, hurricanes, fires, and other severe weather. The incidence and severity of catastrophes are inherently unpredictable. To the extent climate change causes changes in weather patterns, certain regions where we operate could experience increases in storm intensity, extreme temperatures, wildfires, rising sea-levels and/or drought.
In 2022 and 2020, we recorded impairment charges of $1.9 million and $10.7 million, respectively, and recorded an immaterial amount in 2021. If provisions in our corporate documents and Delaware law delay or prevent a change in control, we may be unable to consummate a transaction that our stockholders consider favorable.
Should the value of goodwill or other intangible assets become impaired, there could be an adverse effect on us. If provisions in our corporate documents and Delaware law delay or prevent a change in control, we may be unable to consummate a transaction that our stockholders consider favorable.
Uncertainties in global economic conditions that are beyond our control, including economic downturns, inflation, and slow recovery, a decrease or stagnation in the general level of in-patient admissions or out-patient services at our customers’ facilities, could lead to decreases in demand or pricing for our services.
A decrease or stagnation in the general level of in-patient admissions or out-patient services at our customers’ facilities, could lead to decreases in demand or pricing for our services. When a hospital’s admissions increase, temporary employees or other healthcare professionals are often added before full-time employees are hired.
We are currently evaluating the technology platforms of our businesses, and replacing our legacy nurse and allied applicant tracking system.
We continue to evaluate the technology platforms of our businesses, and have successfully replaced the legacy nurse and allied applicant tracking system, which accounts for a significant portion of our business.
Our operations and financial results have been and may continue to be affected by the ongoing COVID pandemic and changes in national or global economic conditions related thereto. During the COVID pandemic, certain of our healthcare professionals have been exposed, diagnosed and/or quarantined as a result of the virus.
During a pandemic, epidemic, or other public health crisis, certain of our healthcare professionals may be exposed to disease, diagnosed with an illness and/or quarantined as a result of illness.

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Item 2. Properties

Properties — owned and leased real estate

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Biggest changeIn connection with the continuing developments from COVID, we expedited our restructuring plans and either reduced or fully vacated more than 50 leased office spaces during the years ended December 31, 2020 and 2021. See our remaining lease obligations as of December 31, 2022 in Note 9 - Leases to our consolidated financial statements.
Biggest changeIn connection with the developments from COVID, we expedited our restructuring plans and either reduced or fully vacated more than 50 leased office spaces through the year ended December 31, 2021. See our remaining lease obligations as of December 31, 2023 in Note 9 - Leases to our consolidated financial statements.
As of December 31, 2022, our material leased properties are described below: Our corporate headquarters is located in Boca Raton, Florida, with approximately 70,000 square feet of office space under lease through December 2025. Approximately 35,000 square feet is occupied by our corporate executive staff, legal, finance, risk management, internal audit, and information technology teams.
As of December 31, 2023, our material leased properties are described below: Our corporate headquarters is located in Boca Raton, Florida, with approximately 70,000 square feet of office space under lease through December 2025. Approximately 35,000 square feet is occupied by our corporate executive staff, legal, finance, risk management, internal audit, and information technology teams.
Our Physician Staffing executive staff and operations personnel occupy approximately 19,000 square feet with the remainder of the space vacant and available for a sublease.
Our Physician Staffing executive staff and operations personnel occupy approximately 7,000 square feet with the remainder of the space vacant and available for a sublease.
Item 2. Properties. As of December 31, 2022, we actively leased office space in 12 facilities located in 7 states throughout the United States. We also lease office space in a facility located in Pune, India, which houses certain software development and information technology support.
Item 2. Properties. As of December 31, 2023, we actively leased office space in 11 facilities located in 6 states throughout the United States. We also lease office space in a facility located in Pune, India, which houses certain software development and information technology support.

Item 5. Market for Registrant's Common Equity

Market for Common Equity — stock, dividends, buybacks

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Biggest changeThe following table provides information about purchases of our shares of common stock that we made under our New Repurchase Program during the three-month period ended December 31, 2022: Period Total Number of Shares Purchased Average Price Paid per Share Total Number of Shares Purchased as Part of Publicly Announced Plans or Programs Approximate Dollar Value of Shares that May Yet Be Purchased Under the Plans or Programs (a) (dollar value in thousands, except per share data) October 1 through October 31 — — — $87,161 November 1 through November 30 250,000 $31.89 250,000 $79,189 December 1 through December 31 100,000 $29.57 100,000 $76,232 Total 350,000 $31.23 350,000 $76,232 ________________ (a) Represents the remaining value of shares to be purchased under the New Repurchase Program.
Biggest changePeriod Total Number of Shares Purchased Average Price Paid per Share Total Number of Shares Purchased as Part of Publicly Announced Plans or Programs (a) Approximate Dollar Value of Shares that May Yet Be Purchased Under the Plans or Programs (b) (dollar value in thousands, except per share data) October 1 through October 31 137,800 $23.35 137,800 $80,436 November 1 through November 30 167,092 $19.02 167,092 $77,257 December 1 through December 31 — — — $77,257 Total 304,892 $20.98 304,892 $77,257 ________________ (a) Shares were repurchased under the New Repurchase Program.
On August 16, 2022, our Board of Directors authorized a new stock repurchase program (the New Repurchase Program), whereby we may repurchase up to $100.0 million of our shares of common stock, subject to the terms of our current credit agreements. The shares may be repurchased from time-to-time in the open market or in privately negotiated transactions.
On August 16, 2022, our Board of Directors authorized a new stock repurchase program (the New Repurchase Program), whereby we may repurchase up to $100.0 million of our shares of common stock, subject to the terms of our current credit agreement. The shares may be repurchased from time-to-time in the open market or in privately negotiated transactions.
Covenants in our credit agreements limit our ability to repurchase our common stock and declare and pay cash dividends on our common stock.
Covenants in our credit agreement limit our ability to repurchase our common stock and declare and pay cash dividends on our common stock.
The graph assumes that the value of the investment in the Company's common stock and in each of the indexes (including reinvestment of dividends) was $100 on December 29, 2017 and tracks it through December 30, 2022. 22 The stock price performance included in this graph is not necessarily indicative of future stock price performance.
The graph assumes that the value of the investment in the Company's common stock and in each of the indexes (including reinvestment of dividends) was $100 on December 31, 2018 and tracks it through December 29, 2023. 24 The stock price performance included in this graph is not necessarily indicative of future stock price performance.
See Note 14 - Stockholders' Equity to our consolidated financial statements.
See Note 14 - Stockholders’ Equity to our consolidated financial statements for additional information.
As of February 15, 2023, there were 150 stockholders of record of our common stock. In addition, there were 29,076 b eneficial owners of our common stock held by brokers or other institutions on behalf of stockholders. We have never paid or declared cash dividends on our common stock.
As of February 14, 2024, there were 151 stockholders of record of our common stock. In addition, there were 21,575 b eneficial owners of our common stock held by brokers or other institutions on behalf of stockholders. We have never paid or declared cash dividends on our common stock.
In August 2022, we repurchased the remaining shares available for repurchase under the Prior Repurchase Program.
In August 2022, we repurchased the remaining shares available for repurchase under the Prior Repurchase Program. Upon completion of the authorized number of shares available for repurchase under the Prior Repurchase Program, we commenced repurchases under the New Repurchase Program during the third quarter of 2022.
Removed
Upon completion of the authorized number of shares available for repurchase under the Prior Repurchase Program, we commenced repurchases under the New Repurchase Program during the third quarter of 2022. . 23 During the years ended December 31, 2021 and 2020, we did not repurchase any shares of our common stock.
Added
During the year ended December 31, 2021, we did not repurchase any shares of our common stock. 25 The following table sets forth the number of shares purchased, the average price paid per share, the total number of shares purchased as part of publicly announced programs, and the approximate dollar value of shares that may yet be purchased under the programs during each month in the fourth fiscal quarter ended December 31, 2023.
Removed
In August 2022, we repurchased the remaining shares available for repurchase under the Prior Repurchase Program. Item 6. [Reserved].
Added
The program has no expiration date but may be terminated by the Board of Directors at any time. No shares were purchased other than through publicly announced programs during the periods shown.
Added
(b) On May 1, 2023, the Board of Directors authorized approximately $59.0 million in additional share repurchases, such that, effective for trades made after May 3, 2023, the aggregate amount available for stock repurchases under the New Repurchase Program was $100.0 million.
Added
Amounts shown in this column reflect amounts remaining under the New Repurchase Program referenced in Note 14 - Stockholders’ Equity to our consolidated financial statements. Item 6. [Reserved].

Item 7. Management's Discussion & Analysis

Management's Discussion & Analysis (MD&A) — revenue / margin commentary

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Biggest changeYear Ended December 31, 2022 2021 Revenue from services 100.0 % 100.0 % Direct operating expenses 77.6 77.6 Selling, general and administrative expenses 11.6 12.8 Bad debt expense 0.3 0.3 Depreciation and amortization 0.5 0.6 Acquisition and integration-related costs — 0.1 Restructuring costs 0.1 0.2 Impairment charges 0.2 0.1 Income from operations 9.7 8.3 Interest expense 0.5 0.4 Loss on early extinguishment of debt 0.1 — Other income, net — (0.1) Income before income taxes 9.1 8.0 Income tax expense 2.4 0.1 Net income attributable to common stockholders 6.7 % 7.9 % 26 Comparison of Results for the Year Ended December 31, 2022 compared to the Year Ended December 31, 2021 Year Ended December 31, Increase (Decrease) Increase (Decrease) 2022 2021 $ % (Amounts in thousands) Revenue from services $ 2,806,609 $ 1,676,652 $ 1,129,957 67.4 % Direct operating expenses 2,178,923 1,301,653 877,270 67.4 % Selling, general and administrative expenses 324,209 215,292 108,917 50.6 % Bad debt expense 9,609 4,783 4,826 100.9 % Depreciation and amortization 12,576 9,852 2,724 27.6 % Acquisition and integration-related costs 726 1,068 (342) (32.0) % Restructuring costs 1,861 2,630 (769) (29.2) % Impairment charges 5,597 2,070 3,527 170.4 % Income from operations 273,108 139,304 133,804 96.1 % Interest expense 14,391 6,866 7,525 109.6 % Loss on early extinguishment of debt 3,728 — 3,728 100.0 % Other income, net (1,336) (770) (566) (73.5) % Income before income taxes 256,325 133,208 123,117 92.4 % Income tax expense 67,864 1,206 66,658 NM Net income attributable to common stockholders $ 188,461 $ 132,002 $ 56,459 42.8 % NM - Not meaningful Revenue from services Revenue from services increased $1.1 billion, or 67.4%, to $2.8 billion for the year ended December 31, 2022, as compared to $1.7 billion for the year ended December 31, 2021, due to strong performance in both our Nurse and Allied Staffing and Physician Staffing segments, primarily driven by an increase in the number of professionals on assignment, as well as higher bill rates in Nurse and Allied.
Biggest changeYear Ended December 31, 2023 2022 Revenue from services 100.0 % 100.0 % Direct operating expenses 77.7 77.6 Selling, general and administrative expenses 14.9 11.6 Bad debt expense 0.7 0.3 Depreciation and amortization 0.9 0.5 Restructuring costs 0.1 0.1 Legal settlement charges 0.1 — Impairment charges — 0.2 Income from operations 5.6 9.7 Interest expense 0.4 0.5 Loss on early extinguishment of debt 0.1 0.1 Other expense (income), net — — Income before income taxes 5.1 9.1 Income tax expense 1.5 2.4 Net income attributable to common stockholders 3.6 % 6.7 % 28 Comparison of Results for the Year Ended December 31, 2023 compared to the Year Ended December 31, 2022 Year Ended December 31, Increase (Decrease) Increase (Decrease) 2023 2022 $ % (Amounts in thousands) Revenue from services $ 2,019,728 $ 2,806,609 $ (786,881) (28.0) % Direct operating expenses 1,569,318 2,178,923 (609,605) (28.0) % Selling, general and administrative expenses 300,391 324,935 (24,544) (7.6) % Bad debt expense 14,562 9,609 4,953 51.5 % Depreciation and amortization 18,347 12,576 5,771 45.9 % Restructuring costs 2,553 1,861 692 37.2 % Legal settlement charges 1,125 — 1,125 100.0 % Impairment charges 719 5,597 (4,878) (87.2) % Income from operations 112,713 273,108 (160,395) (58.7) % Interest expense 8,094 14,391 (6,297) (43.8) % Loss on early extinguishment of debt 1,723 3,728 (2,005) (53.8) % Other expense (income), net 2 (1,336) 1,338 100.1 % Income before income taxes 102,894 256,325 (153,431) (59.9) % Income tax expense 30,263 67,864 (37,601) (55.4) % Net income attributable to common stockholders $ 72,631 $ 188,461 $ (115,830) (61.5) % Revenue from services Revenue from services decreased $0.8 billion, or 28.0%, to $2.0 billion for the year ended December 31, 2023, as compared to $2.8 billion for the year ended December 31, 2022, primarily driven by a decline in the number of professionals on assignment in the Nurse and Allied Staffing segment as clients continue to right-size their needs, and travel bill rates that continued to normalize throughout the year, partially offset by an increase in volume in most specialties and an improved mix of higher bill rate specialties in the Physician Staffing segment.See further discussion in Segment Results.
We expect to meet our future needs from a combination of cash on hand, operating cash flows, and funds available through the ABL. See debt discussion which follows. In the third quarter of 2022, our Board of Directors authorized the New Repurchase Program, whereby we may repurchase up to $100.0 million of our shares of common stock.
We expect to meet our future needs from a combination of cash on hand, operating cash flows, and funds available through the ABL. See debt discussion which follows. In the third quarter of 2022, the Board of Directors authorized the New Repurchase Program, whereby we may repurchase up to $100.0 million shares of common stock.
On March 21, 2022, we amended the Loan Agreement (Fifth Amendment), which increased the current aggregate committed size of the ABL from $150.0 million to $300.0 million, extended the credit facility for an additional five years, increased certain borrowing base sub-limits, and provided the option for all or a portion of the borrowings to bear interest at a rate based on the Secured Overnight Financing Rate (SOFR) or Base Rate, at the election of the borrowers, plus an applicable margin.
On March 21, 2022, we amended the Loan Agreement (Fifth Amendment), which increased the current aggregate committed size of the ABL from $150.0 million to $300.0 million, 33 extended the credit facility for an additional five years, increased certain borrowing base sub-limits, and provided the option for all or a portion of the borrowings to bear interest at a rate based on the Secured Overnight Financing Rate (SOFR) or Base Rate, at the election of the borrowers, plus an applicable margin.
Revenue per day filled is calculated by dividing revenue as reported by days filled for the period presented. Results of Operations The following table summarizes, for the periods indicated, selected consolidated statements of operations and comprehensive income (loss) data expressed as a percentage of revenue. Our historical results of operations are not necessarily indicative of future operating results.
Revenue per day filled is calculated by dividing revenue as reported by days filled for the period presented. Results of Operations The following table summarizes, for the periods indicated, selected consolidated statements of operations and comprehensive income data expressed as a percentage of revenue. Our historical results of operations are not necessarily indicative of future operating results.
Through our national staffing teams, we offer our workforce solutions and place clinicians on travel and per diem assignments, local short-term contracts, and permanent positions. In addition, we continually evaluate opportunities to acquire companies that would complement or enhance our business, like Mint and HireUp.
Through our national staffing teams, we offer our workforce solutions and place clinicians on travel and per diem assignments, local short-term contracts, and permanent positions. In addition, we continually evaluate opportunities to acquire companies that would complement or enhance our business, like WSG, Mint and HireUp.
Significant judgments are required to estimate the fair value of reporting units including estimating future cash flows, and determining appropriate discount rates, growth rates, company control premium, and other assumptions. Changes in these estimates and assumptions could materially affect the determination of fair value for each reporting unit.
Significant judgments are required to estimate the fair value of reporting units including estimating future cash flows, and determining appropriate discount rates, growth rates, company control premium, and other assumptions. Changes in 34 these estimates and assumptions could materially affect the determination of fair value for each reporting unit.
We have a history of investing in diversity, equality, and inclusion as a key component of the organization’s overall corporate social 24 responsibility program, which we believe is closely aligned with our core values to create a better future for our people, communities, and our stockholders.
We have a history of investing in diversity, equality, and inclusion as a key component of the organization’s overall corporate social responsibility program, which we believe is closely aligned with our core values to create a better future for our people, communities, and our stockholders.
Loss on early extinguishment of debt Loss on early extinguishment of debt for the year ended December 31, 2022 consisted of a prepayment premium and the write-off of debt issuance costs related to the optional prepayments on our term loan made in the second and fourth quarters of 2022.
Loss on early extinguishment of debt for the year ended December 31, 2022 consisted of a prepayment premium and the write-off of debt issuance costs related to the optional prepayments on the term loan made in the second and fourth quarters of 2022.
See Note 5 - Goodwill, Trade Names, and Other Intangible Assets, where impairment testing in 2022, 2021, and 2020 is more fully described. Indefinite-lived intangible assets related to our trade names were not amortized but instead tested for impairment at least annually, or more frequently should an event or circumstances indicate that a reduction in fair value may have occurred.
See Note 5 - Goodwill, Trade Names, and Other Intangible Assets, where impairment testing in 2023, 2022, and 2021 is more fully described. Indefinite-lived intangible assets related to our trade names were not amortized but instead tested for impairment at least annually, or more frequently should an event or circumstances indicate that a reduction in fair value may have occurred.
In addition, we monitor cash flow, as well as operating and leverage ratios, to help us assess our liquidity needs. 25 Business Segment Business Measurement Nurse and Allied Staffing FTEs represent the average number of Nurse and Allied Staffing contract personnel on a full-time equivalent basis.
In addition, we monitor cash flow, as well as operating and leverage ratios, to help us assess our liquidity needs. 27 Business Segment Business Measurement Nurse and Allied Staffing FTEs represent the average number of Nurse and Allied Staffing contract personnel on a full-time equivalent basis.
By utilizing the solutions we offer, customers are able to better plan their personnel needs, optimize their talent acquisition and management processes, strategically flex and balance their workforce, have access to quality healthcare personnel, and provide continuity of care for improved patient outcomes.
By utilizing the solutions that we offer, customers are able to better plan their personnel needs, optimize their talent acquisition and 26 management processes, strategically flex and balance their workforce, have access to quality healthcare personnel, and provide continuity of care for improved patient outcomes.
Restructuring costs Restructuring costs for the years ended December 31, 2022 and 2021 were primarily comprised of employee termination costs and ongoing lease costs related to the Company's strategic reduction of its real estate footprint and totaled $1.9 million and $2.6 million, respectively.
Restructuring costs Restructuring costs for the years ended December 31, 2023 and 2022 were primarily comprised of employee termination costs and ongoing lease costs related to the Company's strategic reduction of its real estate footprint, and totaled $2.6 million and $1.9 million, respectively.
We determine the adequacy of this allowance based on historical write-off experience, current conditions, an analysis of the aging of outstanding receivable and customer payment patterns, and specific reserves for customers in adverse conditions adjusted for current expectations for the customers or industry.
We determine the adequacy of this allowance based on historical write-off experience, current conditions, an analysis of the aging of outstanding receivables and customer payment patterns, and specific reserves for customers in adverse conditions adjusted for current expectations for the customers or industry.
Health, workers' compensation, and professional liability expense We maintain accruals for our health, workers’ compensation, and professional liability claims that are partially self-insured and are classified as accrued compensation and benefits on our consolidated balance sheets.
Health, workers ’ compensation, and professional liability expense We maintain accruals for our health, workers’ compensation, and professional liability claims that are partially self-insured and are classified as accrued compensation and benefits on our consolidated balance sheets.
Discussions of 2020 items and year-to-year comparisons between 2021 and 2020 that are not included in this Form 10-K can be found in “Management’s Discussion and Analysis of Financial Condition and Results of Operations” in the Company’s Annual Report on Form 10-K for the fiscal year ended December 31, 2021 filed with the SEC on February 28, 2022 and such information is incorporated herein by reference.
Discussions of 2021 items and year-to-year comparisons between 2022 and 2021 that are not included in this Form 10-K can be found in “Management’s Discussion and Analysis of Financial Condition and Results of Operations” in the Company’s Annual Report on Form 10-K for the fiscal year ended December 31, 2022 filed with the SEC on February 23, 2023 and such information is incorporated herein by reference.
The determination of the value of such intangible assets requires management to make estimates and assumptions that affect our consolidated financial statements. For intangible assets purchased in a business combination, the estimated fair values of the assets received are used to establish their recorded values.
The determination of the value of such intangible assets requires management to make estimates and assumptions that affect our consolidated financial statements. Historically, for intangible assets purchased in a business combination, the estimated fair values of the assets received were used to establish their recorded values.
We evaluate our estimates on an on-going basis, including those related to asset impairment, accruals for self-insurance, allowance for doubtful accounts and sales allowances, taxes and other contingencies, and litigation. We state our accounting policies in the notes to the audited consolidated financial statements for the year ended December 31, 2022, contained herein.
We evaluate our estimates on an on-going basis, including those related to asset impairment, accruals for self-insurance, allowance for doubtful accounts and sales allowances, taxes and other contingencies, and litigation. We state our accounting policies in the notes to the audited consolidated financial statements for the year ended December 31, 2023.
Our operating cash flow constitutes our primary source of liquidity and, historically, has been sufficient to fund our working capital, capital expenditures, internal business expansion, and debt service. This includes our commitments, both short-term and long-term, of interest expense on our debt and operating lease commitments, and future principal payments on our term loan and our ABL credit facility.
Our operating cash flow constitutes our primary source of liquidity and, historically, has been sufficient to fund working capital, capital expenditures, internal business expansion, and debt service. This includes commitments, both short-term and long-term, of interest expense on our debt and operating lease commitments, and future principal payments on the ABL.
Healthcare insurance accruals 33 have fluctuated with increases or decreases in the average number of corporate employees and healthcare professionals on assignment as well as actual company experience and increases in national healthcare costs. As of December 31, 2022 and 2021, we had $6.2 million and $4.1 million accrued, respectively, for incurred but not reported health insurance claims.
Healthcare insurance accruals have fluctuated with increases or decreases in the average number of corporate employees and healthcare professionals on assignment as well as actual company experience and increases in national healthcare costs. As of December 31, 2023 and 2022, we had $6.6 million and $6.2 million accrued, respectively, for incurred but not reported health insurance claims.
Consolidated Financial Statements and the accompanying notes and other data, all of which appear elsewhere in this Annual Report on Form 10-K. Management's Discussion and Analysis below generally discusses 2022 and 2021 items and year-to-year comparisons between 2022 and 2021.
Consolidated Financial Statements and the accompanying notes and other data, all of which appear elsewhere in this Annual Report on Form 10-K. Management's Discussion and Analysis (MD&A) below generally discusses 2023 and 2022 items and year-to-year comparisons between 2023 and 2022.
As of December 31, 2022 and 2021, our total allowances were $14.7 million and $6.9 million, respectively. Contingent liabilities We are subject to various litigation, claims, investigations, and other proceedings that arise in the ordinary course of our business. These matters primarily relate to employee-related matters that include individual and collective claims, professional liability, tax, and payroll practices.
As of December 31, 2023 and 2022, our total allowances were $20.5 million and $14.7 million, respectively. Contingent liabilities We are subject to various litigation, claims, investigations, and other proceedings that arise in the ordinary course of our business. These matters primarily relate to employee-related matters that include individual and collective claims, professional liability, tax, and payroll practices.
As of December 31, 2022, and 2021, we had $14.9 million and $12.5 million accrued for case reserves and for incurred but not reported workers’ compensation claims, net of insurance receivables, respectively. The accrual for workers’ compensation is based on an actuarial model which is prepared or reviewed by an independent actuary quarterly.
As of December 31, 2023, and 2022, we had $12.6 million and $14.9 million accrued for case reserves and for incurred but not reported workers’ compensation claims, net of insurance receivables, respectively. The accrual for workers’ compensation is based on an actuarial model which is prepared or reviewed by an independent actuary semi-annually.
Based on the information currently available, we also considered current expectations of future economic conditions, including the impact of the ongoing COVID pandemic, when estimating our allowance for doubtful accounts. If the financial condition of our customers were to deteriorate, resulting in an impairment of their ability to make payments, additional allowances may be required.
Based on the information currently available, we also consider current expectations of future economic conditions when estimating our allowance for doubtful accounts. If the financial condition of our customers were to deteriorate, resulting in an impairment of their ability to make payments, additional allowances may be required.
See Note 8 - Debt to our consolidated financial statements. See Results of Operations, Segment Results, and Liquidity and Capital Resources sections that follow for further information. Operating Metrics We evaluate our financial condition by tracking operating metrics and financial results specific to each of our segments.
See Results of Operations, Segment Results, and Liquidity and Capital Resources sections that follow for further information. Operating Metrics We evaluate our financial condition by tracking operating metrics and financial results specific to each of our segments.
Our workforce solutions include MSPs, RPO, project management, and other outsourcing and consultative services as described in Item 1. Business in this Annual Report on Form 10-K.
Our workforce solutions include MSPs, VMS, in- home care services, education healthcare services, RPO, project management, and other outsourcing and consultative services as described in Item 1. Business in this Annual Report on Form 10-K.
As of December 31, 2022, and 2021, we had $4.2 million and $4.9 million accrued, respectively, for case reserves and for incurred but not reported professional liability claims, net of insurance receivables. The accrual for professional liability is based on actuarial models which are prepared by an independent actuary quarterly.
As of December 31, 2023, and 2022, we had $3.1 million and $4.2 million accrued, respectively, for case reserves and for incurred but not reported professional liability claims, net of insurance receivables. The accrual for professional liability is based on actuarial models which are prepared by an independent actuary semi-annually.
As a percentage of revenue, depreciation and amortization expense was 0.5% for the year ended December 31, 2022 and 0.6% for the year ended December 31, 2021.
As a percentage of revenue, depreciation and amortization expense was 0.9% for the year ended December 31, 2023 and 0.5% for the year ended December 31, 2022.
See Note 5 - Goodwill, Trade Names, and Other Intangible Assets and Note 9 - Leases to our consolidated financial statements. Interest expense Interest expense was $14.4 million for the year ended December 31, 2022 compared to $6.9 million for the year ended December 31, 2021, due to higher average borrowings and a higher effective interest rate.
See Note 5 - Goodwill, Trade Names, and Other Intangible Assets and Note 9 - Leases to our consolidated financial statements. Interest expense Interest expense was $8.1 million for the year ended December 31, 2023 as compared to $14.4 million for the year ended December 31, 2022, due to lower average borrowings, partially offset by a higher effective interest rate.
As a percentage of revenue, bad debt expense was 0.3% for the years ended December 31, 2022 and 2021. 27 Depreciation and amortization expense Depreciation and amortization expense for the year ended December 31, 2022 was $12.6 million as compared to $9.9 million for the year ended December 31, 2021.
As a percentage of revenue, bad debt expense was 0.7% for the year ended December 31, 2023, as compared to and 0.3% for the year ended December 31, 2022. Depreciation and amortization expense Depreciation and amortization expense for the year ended December 31, 2023 was $18.3 million as compared to $12.6 million for the year ended December 31, 2022.
Note Payable The first two installments of $2.4 million each related to the subordinated promissory note payable, made in connection with the New Mediscan II, LLC, Mediscan Diagnostic Services, LLC, and Mediscan Nursing Staffing, LLC (collectively Mediscan) acquisition, were paid in the second quarter of 2020 and in the first quarter of 2021, respectively.
Note Payable The first two installments of $2.4 million each related to the subordinated promissory note payable, made in connection with the Mediscan acquisition, were paid in the second quarter of 2020 and in the first quarter of 2021, respectively.
As a percentage of total revenue, selling, general and administrative expenses decreased to 11.6% for the year ended December 31, 2022 as compared to 12.8% for the year ended December 31, 2021. Bad Debt Expense Bad debt expense for the year ended December 31, 2022 was $9.6 million as compared to $4.8 million for the year ended December 31, 2021.
As a percentage of total revenue, selling, general and administrative expenses increased to 14.9% for the year ended December 31, 2023, as compared to 11.6% for the year ended December 31, 2022. Bad Debt Expense Bad debt expense for the year ended December 31, 2023 was $14.6 million as compared to $9.6 million for the year ended December 31, 2022.
The effective interest rate on our borrowings was 9.1% and 5.7% for the years ended December 31, 2022 and 2021, respectively.
The effective interest rate on our borrowings was 10.4% and 9.1% for the years ended December 31, 2023 and 2022, respectively.
Net cash used in investing activities during the year ended December 31, 2022 was $43.9 million compared to $34.0 million in the year ended December 31, 2021. Net cash used in the year ended December 31, 2022 included $35.1 million primarily related to the acquisitions of Mint and HireUp, as well as capital expenditures, primarily related to multiple IT projects.
Net cash used in the year ended December 31, 2022 included $35.1 million primarily related to the acquisitions of Mint and HireUp, as well as capital expenditures primarily related to multiple IT projects.
As of December 31, 2022, we have deferred tax assets related to certain state and foreign NOL carryforwards of $1.4 m illion. But for those NOL carryforwards with an indefinite carryover, the carryforwards will expire as follows: state between 2023 and 2040, and foreign between 2023 and 2027.
But for those NOL carryforwards with an indefinite carryover, the carryforwards will expire as follows: state between 2024 and 2041, and foreign between 2024 and 2028. As of December 31, 2022, we had deferred tax assets related to certain state and foreign NOL carryforwards of $1.4 million.
Impairment charges Non-cash impairment charges totaled $5.6 million for the year ended December 31, 2022 and related to real estate restructuring activities and the write-off of a discontinued IT project. Non-cash impairment charges totaled $2.1 million for the year ended December 31, 2021 and related to real estate restructuring activities and the write-off of a discontinued software development project.
Impairment charges Non-cash impairment charges totaled $0.7 million for the year ended December 31, 2023 and related to the write-off of an IT project and real estate restructuring activities. Non-cash impairment charges totaled $5.6 million for the year ended December 31, 2022 and related to real estate restructuring activities and the write-off of an IT project.
Amounts for the year ended December 31, 2022 include a benefit associated with the early termination of the lease for one of the Company's corporate offices in the second quarter, which was previously restructured.
Amounts for the year ended December 31, 2022 include a benefit associated with the early termination of the lease for one of the Company's corporate offices in the second quarter, which was previously restructured. See Note 2 - Summary of Significant Accounting Policies to our consolidated financial statements.
Other Services Revenue We offer other services to our customers that are transferred over time including: MSPs providing agency services (as further described below in Gross Versus Net Policies), RPO, other outsourcing services, and retained search services, as well as separately billable travel and housing costs, which in total amount to less than 5% of our consolidated revenue for the years ended December 31, 2022, 2021, and 2020.
At December 31, 2023 and December 31, 2022, our estimate of amounts that had been worked but had not been billed totaled $89.9 million and $152.4 million , respectively, and are included in accounts receivable in the consolidated balance sheets. 35 Other Services Revenue We offer other services to our customers that are transferred over time including: MSPs providing agency services (as further described below in Gross Versus Net Policies), RPO, other outsourcing services, and retained search services, as well as separately billable travel and housing costs, which in total amount to less than 5% of our consolidated revenue for the years ended December 31, 2023. 2022, and 2021.
The effective tax rate was 26.5% and 1.0%, including the impact of discrete items, for the years ended December 31, 2022 and 2021, respectively. The effective tax rate in 2022 was impacted by federal, international, and state taxes.
The effective tax rates were 29.4% and 26.5%, including the impact of discrete items, for the years ended December 31, 2023 and 2022, respectively, and were impacted by federal, international, and state taxes.
Other income, net For the year ended December 31, 2022, other income, net included a $1.1 million gain on lease termination as a result of the early termination of one of our corporate offices. 28 I ncome tax expense Income tax expense totaled $67.9 million for the year ended December 31, 2022, compared to $1.2 million for the year ended December 31, 2021.
Other income, net For the year ended December 31, 2022, other income, net included a $1.1 million gain on lease termination as a result of the early termination of one of our corporate offices.
Debt 2021 Term Loan Agreement As more fully described in Note 8 - Debt to our consolidated financial statements, on June 8, 2021, we entered into a Term Loan Agreement, which provides for a six-year second lien subordinated term loan in the amount of $100.0 million (term loan).
Debt 2021 Term Loan Agreement On June 8, 2021, we entered into a Term Loan Agreement, which provided for a six-year second lien subordinated term loan in the amount of $100.0 million (term loan).
As a result of the early prepayments, debt issuance costs of $1.4 million and $1.3 million were written off in the second and fourth quarters of 2022, respectively. The prepayment premiums and the write-off of debt issuance costs are included as loss on early extinguishment of debt in the consolidated statements of operations and comprehensive income (loss).
As a result, debt issuance costs of $1.7 million were written off in the second quarter of 2023 and are included as loss on early extinguishment of debt in the consolidated statements of operations and comprehensive income.
Net cash used in financing activities for the year ended December 31, 2022 was $87.6 million, compared to net cash provided by financing activities of $119.1 million during the year ended December 31, 2021.
Net cash used in financing activities for the year ended December 31, 2023 was $221.2 million, as compared to $87.6 million during the year ended December 31, 2022.
As a percentage of segment revenue, contribution income was 5.2% for the year ended December 31, 2022 and 6.1% for the year ended December 31, 2021, driven by higher revenue, partially offset by higher direct costs. Total days filled increased 35.9% to 60,038 in the year ended December 31, 2022, compared to 44,169 in the year ended December 31, 2021.
As a percentage of segment revenue, contribution income was 5.5% for the year ended December 31, 2023 and 5.2% for the year ended December 31, 2022. Total days filled increased 54.1% to 92,504 in the year ended December 31, 2023, as compared to 60,038 in the year ended December 31, 2022.
Obligations under the Term Loan Agreement are secured by substantially all the assets of the borrowers and guarantors under the Term Loan Agreement, subject to customary exceptions. On November 18, 2021, we amended the Term Loan Agreement (Term Loan First Amendment), which provided the Company an incremental term loan in an aggregate amount equal to $75.0 million.
On November 18, 2021, we amended the Term Loan Agreement (Term Loan First Amendment), which provided the Company an incremental term loan in an aggregate amount equal to $75.0 million.
Revenue per day filled was $1,769 for the year ended December 31, 2022 and $1,605 for the year ended December 31, 2021. Corporate overhead Corporate overhead includes unallocated executive leadership and other centralized corporate functional support costs such as finance, IT, legal, human resources, and marketing, as well as public company expenses and corporate-wide projects.
Corporate overhead Corporate overhead includes unallocated executive leadership and other centralized corporate functional support costs such as finance, IT, legal, human resources, and marketing, as well as public company expenses and corporate-wide projects.
The increase is primarily due to the additional amortization of other intangible assets from the WSG and Selected acquisitions. See Note 5 - Goodwill, Trade Names, and Other Intangible Assets to our consolidated financial statements.
The increase is primarily due to the additional amortization of other intangible assets from the Mint and HireUp acquisitions, as well as depreciation related to computer hardware and software assets placed in service during the year. See Note 5 - Goodwill, Trade Names, and Other Intangible Assets to our consolidated financial statements.
For the year ended December 31, 2022, cash flow provided by operating activities was $134.1 million, with net borrowings of $67.6 million on our senior secured asset-based credit facility (ABL), and an increase in working capital stemming from an increase in accounts receivable partly offset by the timing of disbursements.
For the year ended December 31, 2023, cash flow provided by operating activities was $248.5 million, with net repayments of $150.7 million on our term loan and senior secured asset-based credit facility (ABL), and a decrease in working capital stemming from a decrease in net receivables, partially offset by the timing of disbursements.
In the first quarter of 2023, we expect to amend our Term Loan Agreement to convert the LIBOR rates to SOFR rates. 2019 Loan Agreement Effective October 25, 2019, our prior senior credit facility entered into in August 2017 was replaced by a $120.0 million Loan Agreement, which provides for a five-year senior secured revolving credit facility.
All subsidiary guarantees of the term loan were automatically released upon the termination of the Term Loan Agreement. 2019 Asset-Based Loan Agreement Effective October 25, 2019, the prior senior credit facility entered into in August 2017 was replaced by a $120.0 million asset-based loan agreement (Loan Agreement), which provides for a five-year senior secured revolving credit facility.
On an ongoing basis, we seek to ensure that billing rates reflect increases in costs due to inflation. In addition, we attempt to minimize any residual impact on our operating results by controlling operating costs. Recent Accounting Pronouncements See Note 2 - Summary of Significant Accounting Policies to our consolidated financial statements.
Inflation We do not believe that inflation had a significant impact on our results of operations for the periods presented. On an ongoing basis, we seek to ensure that billing rates reflect increases in costs due to inflation. In addition, we attempt to minimize any residual impact on our operating results by controlling operating costs.
The resulting net revenue represents the administrative fee charged by us for our MSP services. • Revenue from our Physician Staffing business is recognized on a gross basis as we are the principal in the arrangements. 34 Allowances We maintain an allowance for doubtful accounts for estimated losses resulting from the inability of our customers to make required payments, which results in a provision for bad debt expense.
The resulting net revenue represents the administrative fee charged by us for our MSP services. • Revenue from our Physician Staffing business is recognized on a gross basis as we are the principal in the arrangements.
Selling, general and administrative expenses Selling, general and administrative expenses increased $108.9 million, or 50.6%, to $324.2 million for the year ended December 31, 2022, as compared to $215.3 million for the year ended December 31, 2021, primarily due to increases in compensation and benefits, marketing and consulting expense, and computer subscription fees.
Selling, general and administrative expenses Selling, general and administrative expenses decreased $24.5 million, or 7.6%, to $300.4 million for the year ended December 31, 2023, as compared to $324.9 million for the year ended December 31, 2022, primarily due to decreases in compensation and benefit expense, as well as marketing and computer subscription fees, partially offset by increases in legal, insurance, and computer expenses.
See Note 5 - Goodwill, Trade Names, and Other Intangible Assets. In addition, deterioration of demand for our services, deterioration of labor market conditions, reduction of our stock price for an extended period, or other factors as described in Item 1A. Risk Factors , may affect our determination of fair value of goodwill, trade names, or other intangible assets.
These estimates and judgments may also be impacted by the deterioration of demand for our services, deterioration of labor market conditions, reduction of our stock price for an extended period, or other factors as described in Item 1A. Risk Factors.
Corporate overhead increased to $67.1 million for the year ended December 31, 2022, from $55.1 million for the year ended December 31, 2021, primarily due to increases in compensation and benefit expense, legal expense, and computer expense.
Corporate overhead increased to $71.0 million for the year ended December 31, 2023, from $67.1 million for the year ended December 31, 2022, primarily due to increases in consulting, legal expense, and computer expense. As a percentage of consolidated revenue, corporate overhead was 3.5% for the year ended December 31, 2023, and 2.4% for the year ended December 31, 2022.
Cash Flow Comparisons Year Ended December 31, 2022 Compared to Year Ended December 31, 2021 Net cash provided by operating activities during the year ended December 31, 2022 was $134.1 million compared to net cash used in operating activities of $85.6 million during the year ended December 31, 2021.
Cash Flow Comparisons Year Ended December 31, 2023 Compared to Year Ended December 31, 2022 Net cash provided by operating activities increased $114.4 million to $248.5 million for the year ended December 31, 2023 as compared to $134.1 million for the year ended December 31, 2022.
Upon completion of the authorized number of shares available for repurchase under the Prior Repurchase Program, we commenced repurchases under the New Repurchase Program during the third quarter of 2022.
Upon completion of the authorized number of shares available for repurchase under the Prior Repurchase Program, we commenced repurchases under the New Repurchase Program during the third quarter of 2022. During the fourth quarter of 2022, we entered into a Rule 10b5-1 Repurchase Plan to allow for share repurchases during blackout periods, effective through November 2, 2023.
During the third and fourth quarters, we repurchased, under both the Prior Repurchase Program and the New 30 Repurchase Program, a total of 1,364,815 shares of common stock for $35.3 million, at an average market price of $25.83 per share.
During the year ended December 31, 2022, under both programs, we repurchased and retired a total of 1,364,815 shares of common stock for $35.3 million, at an average price of $25.83 per share. As of December 31, 2023, we 32 had $77.3 million remaining for share repurchase under the New Repurchase Program, subject to certain conditions in our Loan Agreement.
Deferred tax assets and liabilities are measured using enacted tax rates expected to apply to taxable income in the years in which those temporary differences are expected to be recovered or settled. During 2021, the Company fully utilized its federal NOL carryforward and a significant amount of state NOLs.
Deferred tax assets and liabilities are measured using enacted tax rates expected to apply to taxable income in the years in which those temporary differences are expected to be recovered or settled. As of December 31, 2023, we have 36 deferred tax assets related to certain state and foreign NOL carryforwards of $1.1 m illion.
Contribution income for the year ended December 31, 2022, increased $149.7 million or 72.8%, to $355.4 million from $205.7 million for the year ended December 31, 2021, driven by increased revenue. As a percentage of segment revenue, contribution income margin increased to 13.2% for the year ended December 31, 2022 from 12.8% for the year ended December 31, 2021.
As a percentage of segment revenue, 31 contribution income margin decreased to 10.7% for the year ended December 31, 2023 as compared to 13.2% for the year ended December 31, 2022.
Working capital increased by $95.5 million to $404.0 million as of December 31, 2022, compared to $308.5 million as of December 31, 2021, primarily due to an increase in accounts receivable, partially offset by the timing of disbursements.
Working capital decreased by $137.4 million to $266.6 million as of December 31, 2023, as compared to $404.0 million as of December 31, 2022, primarily due to a decrease in net receivables, partially offset by the timing of disbursements.
During the year ended December 31, 2021, we reported net borrowings of $175.0 million on our term loan, and used cash to repay borrowing on our ABL of $44.2 million, $0.7 million principal payment on our term loan, $2.4 million on our note payable, $6.1 million of debt issuance costs, $2.2 million for income taxes on share-based compensation, and an immaterial amount for other financing activities.
During the year ended December 31, 2023, we reported net repayments of $150.7 million on debt, and used cash to pay $4.9 million for income taxes on share-based compensation, $57.6 million for share repurchases, $7.5 million for contingent consideration, and an immaterial amount for other financing activities.
Nonetheless, the amounts ultimately paid, if any, upon resolution of the issues raised by the taxing authorities may differ materially from the amounts accrued for each year. Seasonality See Item 1. Business. Inflation We do not believe that inflation had a significant impact on our results of operations for the periods presented.
Nonetheless, the amounts ultimately paid, if any, upon resolution of the issues raised by the taxing authorities may differ materially from the amounts accrued for each year.
An unrecognized tax benefit represents the difference between the recognition of benefits related to exposure items for income tax reporting purposes and financial reporting purposes. For the years ended December 31, 2022 and 2021, the unrecognized tax benefit is included in uncertain tax positions - non-current in the consolidated balance sheets.
For the years ended December 31, 2023 and 2022, the unrecognized tax benefit is included in uncertain tax positions - non-current in the consolidated balance sheets. As of December 31, 2023, total unrecognized tax benefits recorded was $10.6 million.
As of December 31, 2022, our days' sales outstanding, net of amounts owed to subcontractors, was 72 days, up 14 days year-over-year, primarily due to the timing of collections throughout the year. As of December 31, 2022, we do not have any off-balance sheet arrangements.
As of December 31, 2023, our days' sales outstanding, net of amounts owed to subcontractors, was 68 days, down 4 days year-over-year, and excluding the impact from one MSP client, would have been 63 days. As of December 31, 2023, we did not have any off-balance sheet arrangements.
As of December 31, 2022, we had $3.6 million in cash and cash equivalents and a principal balance of $73.9 million outstanding on our term loan. Borrowing base availability under the ABL was $300.0 million, with $76.8 million of borrowings drawn under our ABL, and $18.2 million of undrawn letters of credit outstanding, leaving $205.0 million of excess availability.
As of December 31, 2023, we had $17.1 million in cash and cash equivalents with no borrowings drawn under the ABL. As of December 31, 2023, borrowing base availability under the ABL was $220.6 million with $13.8 million of undrawn letters of credit outstanding, leaving $206.8 million of excess availability. See Note 8 - Debt to our consolidated financial statements.
Contribution income for the year ended December 31, 2022, increased $1.2 million or 27.3% to $5.5 million compared to $4.3 million in the year ended December 31, 2021.
Contribution income for the year ended December 31, 2023, increased $4.3 million or 77.7% to $9.8 million as compared to $5.5 million in the year ended December 31, 2022, driven by higher revenue primarily related to the Mint acquisition.
The SOFR and Base Rate margins are subject to monthly pricing adjustments, pursuant to a pricing matrix based on our excess availability under the revolving credit facility. In addition, the facility is subject to an unused line fee, letter of credit fees, and an administrative fee.
The Base Rate (as defined by the Loan Agreement) margin would have been 0.50% for the revolving portion. The SOFR and Base Rate margins are subject to monthly pricing adjustments, pursuant to a pricing matrix based on our excess availability under the revolving credit facility.
Certain statistical data for our business segments for the periods indicated are as follows: Year Ended December 31, Percent 2022 2021 Change Change Nurse and Allied Staffing statistical data: FTEs 12,980 8,679 4,301 49.6 % Average Nurse and Allied Staffing revenue per FTE per day $ 565 $ 503 $ 62 12.3 % Physician Staffing statistical data: Days filled 60,038 44,169 15,869 35.9 % Revenue per day filled $ 1,769 $ 1,605 $ 164 10.2 % See definition of Business Measurements under the Operating Metrics section of our Management's Discussion and Analysis. 29 Segment Comparison - Year Ended December 31, 2022 compared to the Year Ended December 31, 2021 Nurse and Allied Staffing Revenue increased $1.1 billion, or 68.2% to $2.7 billion for the year ended December 31, 2022, from $1.6 billion for the year ended December 31, 2021, through strong performance driven by volume increases and higher bill rates.
Certain statistical data for our business segments for the periods indicated are as follows: Year Ended December 31, Percent 2023 2022 Change Change Nurse and Allied Staffing statistical data: FTEs 10,831 12,980 (2,149) (16.6) % Average Nurse and Allied Staffing revenue per FTE per day $ 462 $ 565 $ (103) (18.2) % Physician Staffing statistical data: Days filled 92,504 60,038 32,466 54.1 % Revenue per day filled $ 1,927 $ 1,769 $ 158 8.9 % See definition of Business Measurements under the Operating Metrics section of the MD&A.
Segment Results Information on operating segments and a reconciliation to income from operations for the periods indicated are as follows: Year Ended December 31, 2022 2021 (amounts in thousands) Revenues from services: Nurse and Allied Staffing $ 2,700,383 $ 1,605,781 Physician Staffing 106,226 70,871 $ 2,806,609 $ 1,676,652 Contribution income: Nurse and Allied Staffing $ 355,447 $ 205,738 Physician Staffing 5,508 4,328 360,955 210,066 Corporate overhead 67,087 55,142 Depreciation and amortization 12,576 9,852 Acquisition and integration-related costs 726 1,068 Restructuring costs 1,861 2,630 Impairment charges 5,597 2,070 Income from operations $ 273,108 $ 139,304 In the first quarter of 2021, the Company modified its reportable segments and, as a result, now discloses the following two reportable segments - Nurse and Allied Staffing and Physician Staffing.
See Note 14 - Income Taxes to our consolidated financial statements. 30 Segment Results Information on operating segments and a reconciliation to income from operations for the periods indicated are as follows: Year Ended December 31, 2023 2022 (amounts in thousands) Revenues from services: Nurse and Allied Staffing $ 1,841,428 $ 2,700,383 Physician Staffing 178,300 106,226 $ 2,019,728 $ 2,806,609 Contribution income: Nurse and Allied Staffing $ 196,777 $ 355,447 Physician Staffing 9,788 5,508 206,565 360,955 Corporate overhead 71,049 67,087 Depreciation and amortization 18,347 12,576 Restructuring costs 2,553 1,861 Legal settlement charges 1,125 — Impairment charges 719 5,597 Other costs 59 726 Income from operations $ 112,713 $ 273,108 See Note 17 - Segment Data to our consolidated financial statements.
Physician Staffing Revenue increased $35.3 million, or 49.9% to $106.2 million for the year ended December 31, 2022, compared to $70.9 million for the year ended December 31, 2021, primarily due to an increase in volume in several specialties.
Physician Staffing Revenue increased $72.1 million, or 67.8% to $178.3 million for the year ended December 31, 2023, as compared to $106.2 million for the year ended December 31, 2022, primarily related to the Mint acquisition as well as an increase in volume in most specialties and an improved mix of higher bill rate specialties.
The average number of FTEs on contract during the year ended December 31, 2022 increased 49.6% from the year ended December 31, 2021, primarily due to headcount growth in travel nurse and allied, as well as additional headcount resulting from the WSG acquisition .
The average number of FTEs on contract during the year ended December 31, 2023 decreased 16.6% from the year ended December 31, 2022, primarily due to headcount decline in travel nurse and local . Average revenue per FTE per day decreased approximately 18.2% due to the decrease in the average bill rates.
Significant judgment is required in determining our consolidated provision for income taxes and recording the related deferred tax assets and liabilities. In the ordinary course of our business there are many transactions and calculations where the ultimate tax determination is uncertain.
In the ordinary course of our business there are many transactions and calculations where the ultimate tax determination is uncertain. An unrecognized tax benefit represents the difference between the recognition of benefits related to exposure items for income tax reporting purposes and financial reporting purposes.
As of December 31, 2021, we had deferred tax assets related to certain state and foreign NOL carryforwards of $4.5 million. As of December 31, 2022 and 2021, we had an immaterial amount of valuation allowances on our deferred tax assets.
As of December 31, 2023 and 2022, we had an immaterial amount of valuation allowances on our deferred tax assets. We are subject to income taxes in the U.S. and certain foreign jurisdictions. Significant judgment is required in determining our consolidated provision for income taxes and recording the related deferred tax assets and liabilities.
Direct operating expenses increased $877.3 million, or 67.4%, to $2.2 billion for the year ended December 31, 2022, as compared to $1.3 billion for the year ended December 31, 2021, as a result of revenue increases. As a percentage of total revenue, direct operating expenses were 77.6% for the years ended December 31, 2022 and 2021.
Direct operating expenses Direct operating expenses consist primarily of field employee compensation and independent contractor expenses, housing expenses, travel expenses, and related insurance expenses. Direct operating expenses decreased $0.6 billion, or 28.0%, to $1.6 billion for the year ended December 31, 2023, as compared to $2.2 billion for the year ended December 31, 2022, as a result of revenue decreases.
Net income attributable to common stockholders for the year ended December 31, 2022 was $188.5 million, as compared to $132.0 million for the year ended December 31, 2021.
In Education, the average number of FTEs on contract during the year increased 23%, and in the Physician Staffing segment the number of days filled increased across several specialties. Net income attributable to common stockholders for the year ended December 31, 2023 was $72.6 million, as compared to $188.5 million for the year ended December 31, 2022.
As of December 31, 2022, the interest rate spreads and fees under the Loan Agreement were based on SOFR plus 1.85% for the revolving portion of the borrowing base. The Base Rate (as defined by the Loan Agreement) margin would have been 0.75% for the revolving portion.
On September 29, 2023, we amended the Loan Agreement (Sixth Amendment), which changed the minimum fixed charge coverage ratio from a maintenance covenant to a springing covenant based on excess availability. As of December 31, 2023, the interest rate spreads and fees under the Loan Agreement were based on SOFR plus 1.60% for the revolving portion of the borrowing base.
Borrowing base availability under the ABL was $300.0 million at December 31, 2022, with $76.8 million of borrowings drawn as well as $18.2 million of letters of credit outstanding, leaving $205.0 million of excess availability.
In addition, the facility is subject to an unused line fee, letter of credit fees, and an administrative fee. Borrowing base availability under the ABL was $220.6 million at December 31, 2023, with no borrowings drawn and $13.8 million of letters of credit outstanding, leaving $206.8 million of excess availability.
Summary of Operations For the year ended December 31, 2022, revenue from services increased 67% year-over-year to $2.8 billion, due to strong performance in both our Nurse and Allied Staffing and Physician Staffing segments, primarily driven by an increase in volume growth and the number of professionals on assignment as a result of our investment in people and technology.
Summary of Operations For the year ended December 31, 2023, revenue from services decreased 28% year-over-year to $2.0 billion, due primarily to travel and local volume and average bill rate declines in the Nurse and Allied Staffing segment, partially offset by double-digit year-over-year revenue growth in Cross Country Education (Education) within the Nurse and Allied Staffing segment, and in the Physician Staffing segment.
As of December 31, 2022, we had $76.2 million remaining for share repurchase under the New Repurchase Program, subject to certain conditions in our Loan Agreement and Term Loan Agreement. During the fourth quarter of 2022, we entered into a Rule 10b5-1 Repurchase Plan to allow for share repurchases during our blackout periods.
In the third quarter of 2023, we entered into a new Rule 10b5-1 Repurchase Plan to allow for share repurchases during the Company's blackout periods, beginning on January 2, 2024. During the year ended December 31, 2023, we repurchased and retired a total of 2,343,583 shares of common stock for $57.6 million, at an average price of $24.58 per share.
As a percentage of consolidated revenue, corporate overhead was 2.4% for the year ended December 31, 2022, and 3.3% for the year ended December 31, 2021. Liquidity and Capital Resources At December 31, 2022, we reported $3.6 million in cash and cash equivalents, $73.9 million of term loan outstanding, at par, and $76.8 million of borrowings drawn under our ABL.
Liquidity and Capital Resources On June 30, 2023, we repaid all $73.9 million in outstanding obligations under the term loan and terminated the debt agreement. At December 31, 2023, we reported $17.1 million in cash and cash equivalents, with no borrowings drawn under the ABL.
Risk and Uncertainties The calculation of fair value used in these impairment assessments included a number of estimates and assumptions that required significant judgments, including projections of future income and cash flows, long-term growth rates, the identification of appropriate market multiples, royalty rates, and the choice of an appropriate discount rate.
These estimates are based on information that is currently available to us and on various assumptions that we believe to be reasonable under the circumstances, but come with certain risks and uncertainties, including but not limited to: projections of future income and cash flows, market demand, inflationary pressures, long-term growth rates, the identification of appropriate market multiples, royalty rates, and the choice of an appropriate discount rates.

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Item 7A. Quantitative and Qualitative Disclosures About Market Risk

Market Risk — interest-rate, FX, commodity exposure

3 edited+0 added−0 removed5 unchanged
Biggest changeThese agreements charge interest at a rate based on either SOFR, LIBOR, or Base Rate (as defined in the respective agreements) plus an applicable margin. A 1% change in interest rates would have resulted in interest expense fluctuating approximately $1.5 million and $1.1 million, respectively, for the years ended December 31, 2022 and 2021.
Biggest changeOur Term Loan Agreement, entered into on June 8, 2021, was repaid and terminated on June 30, 2023. A 1% change in interest rates would have resulted in interest expense fluctuating approximately $0.6 million and $1.5 million, respectively, for the years ended December 31, 2023 and 2022. See Note 8 - Debt to our consolidated financial statements.
See Note 8 - Debt to our consolidated financial statements. 36 Foreign Currency Risk We have minor exposure to the impact of foreign currency fluctuations. Approximately 1% of selling, general and administrative expenses are related to certain software development and information technology support provided by our employees in Pune, India.
Foreign Currency Risk We have minor exposure to the impact of foreign currency fluctuations. Approximately 1% of selling, general and administrative expenses are related to certain software development and information technology support provided by our employees in Pune, India.
Item 7A. Quantitative and Qualitative Disclosures about Market Risk. Interest Rate Risk We are exposed to variable interest rate risk associated with our Term Loan Agreement entered into on June 8, 2021 and our Loan Agreement entered into on October 25, 2019.
Item 7A. Quantitative and Qualitative Disclosures about Market Risk. 37 Interest Rate Risk We are exposed to variable interest rate risk associated with our Loan Agreement entered into on October 25, 2019. This agreement charges interest at a rate based on either SOFR or Base Rate (as defined in the agreement) plus an applicable margin.

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